ML20215J273

Partially Withheld Memo Informing Commission of NRR General Findings & Conclusions on Preaccident RCS Leak Rate Surveillance Testing Practices at Facility & Recommendations Re Operators Involved in Irregularities

ML20215J273
Person / Time
Site:	Three Mile Island
Issue date:	04/01/1986
From:	Stello V NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO)
To:	Asselstine, Palladino, Roberts NRC COMMISSION (OCM)
Shared Package
ML20215J278	List: ML20215J273 ML20215J291
References
NUDOCS 8610240376
Download: ML20215J273 (39)

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. APR 01 M MEMORANDUM FOR: Chairman Palladino Comissioner Roberts Comissioner Asselstine Comissioner Bernthal Comissioner Zech t

, TROM:, Victor Stello, Jr. -

Acting Executive Director for Operations

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SUBJECT:

RESULTS OF NRR'S INVESTIGATION AND EVALUATION OF TEN I

LICENSED OPERATORS INVOLVED IN THI-2 PREACCIDENT LEAK RATE TESTING IRREGULARITIES Purpose The purpose of this memorandum is to inform the Comission of: (1)theOffice of Nuclear Reactor Regulation's (NRR's) general findings and conclusions stem leak rate surveillance testing regarding practices atpreaccident reactorUnit Three Mile Island, coolant 2 sy(TMI-2); and (2) NRR's conclusions and recomendations regarding ten licensed operators involved in preaccident leak rate testing irregularities, . With respect to the ten operators. NRR's report addresses both the past wrongdoing and the current perfomance of the -

individuals. TheOfficeofInvestigations(01) Report (1-84-022),which addresses past wrongdoing only, is being fomarded to the Comission by 0!

under separate cover.

Background

As the result of Comission meetings on March 23, 1984 and May 23, 1984, O!

. and NRR were directed to jointly . investigate what role, if any, ten licensed individuals had in improper activities associated with reactor coolant system leak inte surveillance testing at THI-2 before the accident. Based upon the '

re5J1ts of the joint O!/NRR investigation into past wrongdoing and NRR's evaluation of the individuals' current performance, NKR was to recomend to NDH: The information covered in this remorandum and enclosures is the subject of an ongoing 0! investigation and information that is maintained in the NRC's Privacy Act System of Records (NRC-16).

The 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.

Contact:

William T. Russell, NRR 492-4803 8610240376 860401 PDR ADOCK 05000320 P PDR

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the Comission what action, if any, should be taken for these individuals. Of the ten individuals identified for investigation and evaluation, seven are currently licensed at THI-2 and one is licensed at San Onofre 2/3. The other two individuals were licensed on Waterford 3, but subsequently left. Louisiana Power and Light Company.

During the course of the joint investigation, some individuals may have made false statements regarding their past involvement in leak" rate testing irregu '

larities. Since these individuals were licensed senior operators, it was necessary for NRR to determine whether or not the individuals should be allowed to continue to perform activities related to public health and safety. NRR evaluated each individual's past improper conduct, the completeness and accuracy of his testimony, his knowledge of licensed duties and responsibilities and his current performance. NRR's report balancing these factors was prepared for each individual shortly after their interviews. Copies of these reports are included as enclosures 3, through,12. , , ,

(

By memorandum from the Executive Director for Operations (EDO) dated December 18, 1984, copies of the NRR reports for the San Onofre 2/3 operator and both Waterford 3 operators were provided to the Commission. O! and NRR briefed the l Commission on the investigation results and NRR's reconrnended actions. The

. Comission subsequently decided to defer a decision on actions against these individuals until the entire investigation was completed.

In its February 25, 1985 decision (CLI-85-2), the Comission decided it would institute a hearing on the TMI-2 leak rate falsification issue. This hearing 1

was to develop the facts surroundir.g leak rate falsification at TMI-2 in

sufficient detail to detemine the involvement of individuals. As a result of

! this Commission decision, NRR has not implemented its recommended actions.

Discussion As part. of tt e investigation, NRR perfomed a technical evaluation of leak rate tests performed during the last 6 months of operation at TMI-2 and Ol/NRR inter-viewed the ten individuals under investigation. In order to gain additional background information, 01/NRR conducted interviews with five fomer TMI-2 control room operators (CR0s) who stood watch with the individuals under

investigation. Based upon operator interviews and the technical evaluation of l

leak rate tests, NRR developed general findings and conclusions regarding leak rate surveillance testing practices at THI-2 during the period October 1578 through March 1979. These general findings and conclusions are provided as l Enclosure 1.

On September 9,1985, GPU Nuclear Corporation (GPUN) forwarded its investigation report, entitled "THI-2 Reactor Coolant Inventory Balance Testing," prepared by Mr. Edwin H. Stier (Stier Report). This report addresses leak rate surveillance testing practices at THI-2 for a 1-year period before the accident. The Stier Report findings regarding leak rate testing practices and test manipulation are j

generally-consistent with NRR's conclusions.

1 I

3 e

Enclosure 2 contains a sumary of NRR's findin tions (extracted from Enclosures 3 throughfor 12)gs, conclusions the ten individualsand recomenda-under investigation and where applicable, includes a synopsis of the Stier Report conclusions regarding these individuals. Transcripts of the 0!/NRR interviews and NRR's technical evaluation of leak rate tests have not been included in enclosures 3 through 12 since copies of these documents are exhibits in the O!

Report (1-84-022). Enclosures 13 through 17 are NRR's background interview sumaries of five other operators.

Conclusion On February 28,1984, Metropolitan Edison Company, pled guilty to one criminal felony count, Section 223 of the Atomic Energy Act, and nolo contendere to l six counts of a criminal indictment, charged under the Atomic Energy Act, associated with TMI-2 leak rate' testing. The Court accepted the plea agreement l

on February 29,1984. NRR's technical evaluation and operator testimony during l the joint 01/NRR investigation confim that many of the practices associated with the perfomance of leak rate surveillance tests at 1?i!-2 violated the technical specifications and approved plant procedures. It is also apparent that licensee's standards for procedural compliance in this area were lax and pennissive. This attitude toward procedural compliance was created by super-visory and management personnel.

i The leak rate surveillance test was the only method operators had to quantify i unidentified leakage in order to demonstrate conpliance with the TMI-2 Technical Specifications. Because of the variability of the test.results, most operators did not consider the test to be a true measure of actual plant leakage. Based on postaccident evaluation of the leak rate test procedure, the operators were correct. NRR believes that many instances occurred where leak -

rate test results were in excess of the technical specification limit; yet, the actual unidentified leakage did not exceed 1 gpm.

Based on operator testimony, when leak rate test results exceedeff the technical .

specification limits, a conscious decision was made by Shift Supervisors, and possibly management personnel, to disregard the requirements of the technical specifications. While direct leak rate manipulation did occur on some shifts, it is apparent that all shifts performed the test with little regarTTor its validity. If test resuits exceeded the technical specification limit, the '

results were discarded and another test conducted. If test results were below the technical specification lir.it, they were retained to satisfy the

" administrative requirement." However, these results received little or no review, regardless of the plant conditions or evolutions in progress which may have rendered the test invalid. These actions, coupled with the lack of confi-dence in the leak rate test procedure and management's failure to correct test procedure problems and instill high standards for procedural compliance, led to conditions where leak rate tests were conducted in a frivolous manner and where operators were activated, in some cases, to manipulate or falsify leak rate test results.

Based on the Comission decisions discussed earlier NRR has not implemented its l recomended actions for these currently licensed operators. Although NRR con-l cluded that there is reasonable assurance that all ten operators would fulfill l

• ENCLOSURE 1 FINDINGS AND CONCLUSIONS REGARDING 1MI-2 LEAK RATE TESTING IR 1 INTRODUCTION q..

NRR has worked with DI on investigations of 10 currently licensed operators l

in order to determine their involvement, if any in improper activities associated with reactor coolant system (RCS) leak rate surveillance testing at TMI-2 before the accident.

- As a result of these investigations, NRR has performed a technical evaluation of leak rate tests performed at TMI-2 during the period September 30, 1978 to March 28, 1979. 'In addition, joint 01/NRR interviews have been conducted with 13 former control room operators (CR0s) and two shift foremen. A detailed report has been prepared by MRR on each of the 10 individuals under -

- investigation identifying the individual's role in leak rate testingOn the irregularities and evaluating the individual's current performance.

basis of these reports, some general findingt and conclusions can be drawn.

Therefore. the purpose of this enclosure is to provide a consolidated sumary

-- of MRR's findings and conclusions regarding leak rate testing practices during the last 6 months of operation at TMI-2.

~ To understand the basis for these findings and conclusions, a short discus-sion of the TMI-2 Technical Specifications and procedural requirements associated with leak rate testing is presented followed by a brief sumary of NRR's technical evaluation. The staff's findings and conclusions are pre-sented at the end of this enclosure.

. 2 TMI-2 REQUIREMENTS '

TMI-2 Technical Specification 3/4.4.6.2. "Peactor Coolant System Operational

- - '- Leakage." provided the limiting conditions for operation (LCO) associated

• ~.- . with RCS leakage, the surveillence requirements to be performed to demon-strate conformance with the LCD, and the required action statements if the.. _

, . LCO were exceeded.

Technical Specification 3.4.6.2.b specified that the LC0 for unidentified le6kage was 1 gpm. If this LCO was exceeded. Action Statement 3.4.6.2.b required that leakage be reduced to within operating limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or the plant was to be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in cold shutdown within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.

To demonstrate confomance with the LCO. Surveillance Requirement 4.4.6.2.d required the performance of a reactor coolant system water inventory balance (leak rate test) at least once per 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.

NOTE:

This enclosure discusses information which is the subject of an This enclosure may not be disseminated ongoing 01 investigation.outside the NRC without coordination with NR l

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

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2-Surveillance Procedure (SP) 2301-3D1, "RC System Inventory " was'the approved procedure governing the conduct of leak rate tests. Section.I.2 of the procedure stated that if unidentified leakage exceeded 1 gpm, the operator was to proceed with Technical Specification Action Statement.3it.6.2.b.

In addition. Section 6.4 of the procedure required the operatof to conduct the following four steps:

(1) Another leak rate test was to be performed.

(2) Whether unaccounted for o>erator action had occurred that would change the RCS inventory was to >e determined. If such an action occurred, it invalidated the measurement. The action kvalidating the measurement was to be recorded in the remarks section of the data sheet.

(3) Action so determine the source of leakage was to be initiated. _

(4) If the source of leakage was found, the source of the leakage and the leak rate were to be documented and entered on the appropriate data sheet. The shift supervisor was then required to make the .

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initial determination of the safety implications of the leak.

According to SP 2301-301, the preferred method of performing leak rate tests

- was with the plant computer. To initiate the test, the operator would enter the proper codes into the computer, including the duration of the test. In all cases that were evaluated, a test period of I hour was selected. The computer would automatically collect the necessary plant data at the beginning and and of the test period. At the end of the 1-hour test period, the operator was required to enter known leakage and any operator-caused changes in inventory from the reactor coolant drain tank (RCDT) or the RCS: '

The computer would then print the initial and final values of key plant parameters and the calculated values for gross leak rate, total identified leak rate, and net unidentified leak rate.

The computer-generated leak rate surveillance test sheet would normally be -

signed by the CR0 performing the test and approved by a senior reactor oper-ater(SRO). In most casts, the shift foreman approved tests run on his shift.

THI-2 Technical Specification 6.10.1, " Record Retention," required that records of surveillance activities required by the Technical Specifications be retained for at least 5 years.

Section 3.3.17 of TMI Administrative Procedure 1012. " Shift Relief and Log Entries," required that the performance of all periodic tests and inspections required by the Technical Specifications be recorded in the Control Room Log. '

Required entries included the title and number of the test performed and the start and completion times, or time of suspension, of the tatt Section 6.5 of TM1 Administrative Procedure 1010. " Technical }pecification SurveillanceProgram."requiredoperatorstorecordanygroblemsthatwere encountered while performing surveillance testing on an Exception and Deficiency List." This list was to be attached to the completed Surveillance Test Data Sheet. All exceptions and deficiencies were to be imediately

evaluatedandinitialed(toshowreview)bytheshiftsupervisor,to' determine if they constituted a reportable occurrence. The procedure further' defined a l

• deficiency" as a problem relating to the test results not setting the -

' acceptance criteria of the test.

3 TECHNICAL EVALUATION During the period under investigation. September 30, 1978 to March 28, Ig79, plant records show that 161 leak rate surveillance tests were retained by the licensee. Documentation for each test was evaluated by NRR to detemine whether the test met the acceptance criteria and whether operator actions or plant conditions may have occurred during the test that violated the limits and precautions of SP 2301-3D1, thus rendering the test invalid. All of the 161 tests were classified as valid or invalid. The invalid tests were further subdivided into at least one of eight categories as shown by the table below:

Sumary of Leak Rate Tests by Evaluation Category Number /1 Evaluation Category

-].i 161 Total Tests on F11e...........................................

, 50 31 V al i d Te s ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

111 69 Invalid Tests.................................................

42 26

• Unstable or inaccurate data provided to the plant computer..

22 14  :

• Water additions r.ot included in the calculation.............

l 17 11

• Water additiens partially included in the calculation.......

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15 9

• Feed and bleed operations not included in the calculation...

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I 12 7

- *Hydrogenadditionstotheaske-uptank(MUT)................

10 6

• Unstable plant conditions during test.......................

7 4

• Water or hydrogen addition to MUT (unable to differentiate). .

6 4

• Unidentified leakage greater than the TS limit..............

Note: Fourteen tests fall into two categories and three tests .-

fell into three categories.

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As can be seen by this table, only 50 of the 161 leak rate tests were evalu-t ted as being performed in accordance with approved plant procedures and yielded results that were less than the technical specification limit. A brief discussion of each of the test categories is provided ho3ew.

3.1 No Apparent Problem -- -

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This category was used for tests that appeared to have been conducted in accordance with the requirements of $P 2301-3D1. The surveillance test sheet, CRO's and Shift Foreman's Logs, and makeup tank (MUT) strip chart had no unusual characteristics or features that called into question the validity of the test. In addition, the actual change in MUT 1evel during the test was consistent with the expected change caused by differences in pressurizer level (Lp) and average RCS temperature (Tave) during the test.

! During September 30 through December 31. 1978. 30 normal tests were performed l

out of 82 (37%). These tests were fairly well distributed between the fivs l

shifts (A through E). Between January 1 and March 28,1979, a sixth shift _

(F)wascreated. Because of the high rate of identified leakage from the top

- of the pressurizer through either the pilot-operated relief valve (PORV)

and/or code safety valves, this was a period where satisfactory leak rate tests became harder to obtain. Duringthispericd.only20outof74(27%)

tests were considered normal. The majority of these tests were performed by shifts A and F.

l 3.2 Unstable plant Conditions SP 2301-3D1 directed that the test be performed at least once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady-state operation when in Modes 1 through 4. The procedure -

cautioned the operator to maintain the reactor coolant system and makeup .

- system in a steady-state condition during the test by avoiding changes in ,

valve lineups, coolers in service, pumps in service, etc. Power level changes should be minir.ized, and the operator should avoid additions or

- - removal of water from the RCS and makeup system during the test. For the

- mest accurate deterrination of RCS leak rate, the initial and finct conditions of reactor power RCS temperature, pressure and pressurizer level should be identical. Tests in this category had obvious problems with large fluctuations in key plant parameters and were not conducted during stable plar.t or steady-state conditions.

During the 6-month period. 10 tests were conducted during unstable plant conditions. All six shifts were involved in conducting one or more of these tests.

3.3 Instrumentation Problems Makeup tank level is ona of the key plant parameters used in the leak rate calculation. At THI-2, there are two level transmitters (LT4 and LT-2) that provide MUT level indication. The output of one of the level , transmitters

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drives the MUT level strip chart in the control room while the other level transmitter provides MUT level indication to the plant computer. When the selector switch was positioned to LT-1, the strip chart recorder *ould be driven by the output of LT-1 and LT-2 would provide automatic input to the plant computer. When the selector switch was changed to LT-frthe opposite would occur. ,, ,

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Between October 30 aid November 6,1978, operators experienceDroblems with both level transmittars. At various times during this period, the level transmitters were reading radically different levels in the MUT. and both were taken out of service for maintenance work and recalibration. During this period, eight leak rate tests were conducted. Only two of the tests appear normal. During four of the tests, the difference between LT-1 and LT-2 ranged from 13 in. to 15 in. and during two of the tests, the LT feeding the computer was reading off-scale high at 99 in. Only the shift A operators were not involved in any of the six invalid tests.

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

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performed with the use of LT-1 prcviding input to the computer must be

-1 considered questionable or invalid. Of the 50 tests conducted by all shifts

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during this period, only 16 (325) were performed with the stable level transmitter (LT-2)providinginputtothecomputerduringthetest. During

- this period, all shifts switched back and forth between the two level transmitters and ran tests using both LT-1 and LT-2. These actions suggest that operators were aware of instrumentation problems at the time.

3.4 Hydrogen Additions To limit the oxygen content in the RCS and to provide an increased net .

positive suction head for the RC makeup pumps, a hydrogen overpressure was-maintained in the MUT. When hydrogen 1ressure decreased near the low end of

.s the operating band, the CR0 would add vdrogen to the tank.

1 s. . .

Theoretically, the addition of hydrogen should not have affected MUT tevel;.

however, because of the design of the MUT level detection instrumentatiert system.at TMI-2 water could collect in the low-pressure (dry) reference leg of the level transmitters. Under this condition, the resultant water slug or

" loop seal" could cause a temporary increase in MUT indicated level without actually adding water to the tank. Thus, the addition of hydrogen at the appropriate time (after the computer collected its initial data and before thefinaldataweretaken)couldaffecttheleakrateresultsina nonconservative manner (i.e., the calculated leak rate would be less than the actualleakrate). AccordingtoformerCR0HaroldHartman(ShiftE),this "cause and effect' relationship was cosmon knowledge among operators.

Hartman and four other CR0s on shifts C. D. and E have admitte'd adding hydrogen to the MUT during leak rate tests to influence the outcome of the tests. Out of the 12 hydrogen additions identified in the technical ,

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. i 6-e 1 evaluation, the majority were performed by operators on shifts 8 and C.

Shift A is the only shift where no hydrogen additions were identified during leak rate tests. However, this method of test manipulation may'have been used more times than are reflected in the technical evaluatiofrTor three reasons. First, hydrogen would have an effect on MUT level only if sufficient water were present to form a loop seaf.' Second, dater might collect in the reference-leg of one LT and not in the c,ther. Thus, causing one LT to react to the addition and not the other. Third, hydrogen additions were not always logged, or if logged, were not always logged at the time the addition was made. Thus. identifying the addition of hydrogen on the MUT strip chart is difficult. 1 3.5 Water Additions not Included in the Calculation EP 2301-3D1 instructed the operator to avoid the addition and' removal of water from the RCS and makeup system during the test; however, if the in-

, _ - ventory must be changed. it must be accounted for by including the amount of water added in the test calculation. Normally, water was added to the MUT in amannerthatiseasilydetectableontheMUTstripchart(batchaddition).

If, however, water was added in small quantities over a period of time

.J. (jogged addition), the water addition may be masked by normal oscillations on

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the MUT strip chart. According to Hartman, jogged additions were made to the ACS during the performance of leak rate tests by his shift and the amount of water added was not included in the test calculation in order to manipulate the outcome of the test. The technical evaluation identifies tests where batch additions and possible jogged water additions were made to the MUT during the test and not included in the leak rate calculation.

The technical evaluation identifies 22 tests. involving all six shifts, where water additions may have been made to the MUT and not included in the leak.

- rate calculation. Shift E operators were involved in nine of these tests .

followed by shift B with six tests and shifts C and D with five tests. Shift A and F operators were involved in only two and three of these tests.

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- r.aspectively. ~

3.6~ Water Additions Partially included in the Calculation _

! This category includes leak rate tests where water additions were made to the

- MUT during the test and were included in the leak rate test calculation.

However, because of two TicTors, the test results showed lower leakage than would otherwise have been the case without the water addition.

The first factor was an error in the test procedure itself. SP 2301-3D1 did not convert the amount of water added to the same temperature as the RCS. As a result, the water added to the MUT was " undervalued" and tended to reduce the total and unidentified leak rate as calculated in the test. (Note: This error was only one of several that contributed to inaccurate results.)

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The second factor involved MUT level instrument errors. Because adding water to the MUT compressed the hydrogen gas in the top of the MUT. water additions to the tank shortly before the computer obtained its final data, set could have the same result as a hydrogen addition. If an operator were aware of this cause-and-effect relationship, he could take advantage ST~this phenome-non to manipulate test results by following the procedure exactly as written.

For example, the addition of 150 gal of water to the MUT durivig the last 10 minutes of a leak rate test should cause the MUT level to increase approxi-mately 5 in. (30 gal / inch); however if sufficient water had collected in the loop seal, the indicated level on the MUT strip chart might actually increase 6in.(180 gal). Once the final data were read by the computer. including the 6-in, rise in MUT level, the operator would enter the 150-gal water

- addition (as read off the totalizer on the batch controller) into the.

computer as an operator-cause change. Thus, when the computer calculated the total and unidentified leak rate, the results would be 0.5 gpa less than the actualleakrate(180 gal-150 gal /60 min). Note: While operators used 30 gal / inch as a rule of thumb, the actual value was approximately 30.8 gal / inch

-- - at normal MUT conditions. --.

NRR does not believe that operators were aware of the procedural error in the calculation; however, on the basis of the testimony of former CR0 Mark

- '- Coleman (Shift D), who was aware of the MUT level instrument inaccuracy and used this mechanism to influence leak rate tests, other operators also may have been aware of the phenomenon and used it to their advantage.

The technical evaluation identifies 23 tests where water was added to the MUT and the water addition was included in the test calculation. For six of these tests. the amount of water included in the calculation closely matches the amount indicated on the MUT strip chart. Four of these tests were per-formed by shift A with the other two tests were performed by shifts D and F.

.For the remaining 17 tests, the amount of water included in the calculation

• was significantly less than the amount indicated on the MUT strip chart.

Shift D operators were involved in 12 of these tests, shift F in 3 tests, and

- shift A and 8 operators each performed 1 test.

3.7. Feed and Bleed Operations The technical evaluation identifies 15 tests during which feed and bleed operations may have occurred. Feed and bleed operations were used routinely to increase or decrease the boron concentration in the RCS. Based on the limits and precautions of SP 2301-301 feed and bleed operations should not have been conducted during leak rate tests.

Feed and bleed operations like many others in the plant, do not always have a distinctive trace on the MUT strip chart. Attimes,waterwasadded(feed) and then removed (bleed) from the RCS. in that order. At other times, the reverse order was used. Because water also could be added ,and removed from l

the system at the same time, these operations might be undetectable on the strip chart if the rate of addition and removal was equal and the operation was not logged in the Control Room Log. While feed and bleed 1pperations could be used to manipulate test results, none of the operators. interviewed

' -(, .

by 01/NRR have admitted using this method.

Shift C operators were involved in 7 of the 15 tests where possible feed and

, bleed operations occurred during the test. The remaining eight tests were split fairly svenly between shifts B. D. E. and F. Only shift A operators were not involved in any of the 15 tests.

3.8 Water or Hydronen Additions The technical eva'luation identifies seven tests where it appears the test results may have been influenced by either a hydrogen addition or a jogged water addition. On the basis of the similarity in MUT level traces that --

could be produced by either a small water or hydrogen addition, it was not-possible to differentiate between these two types of additions for these seven tests.

I .b Shift C operators were involved in three of the tests and shift B operators in two tests. Operators on shifts E and F were each involved in one test.

3.9 Unidentified Leakene Greater Then 1 eum The six tests in this category all occurred between October 16 and 18.1978.

Each of these tests showed results greater than the technical specification limit for unidentified leakage. Four tests were not signed by the CR0 performing the test, ar.d five were not approved by the shift foreman. The

- sixth test was not signed by a CRO. instead the shift foreman signed as the.

operator perforining the test and the shift supervisor approved the test. All six tests were associated with an incident that occurred on October 16, 1978 resulting in the submission of LER 78-62/1T by Met-Ed on November 1.1978. ~

3.10 Technical Evaluation Summary _

In sunnary. NRR's technical evaluation shows that between September 30. 1978 and March 28,1979.111ofthe161 tests (691)includedactionsthatwere contrary to the requirements of the Technical Specifications and the precau-tions. limitations, and requirements of Surveillance Procedure 2301-3D1.

These actions included unsigned and unapproved test results greater than the technical specification limit, tests conducted during unstable plant con-ditions, tests conducted with unreliable or inaccurate instrumentation providing input to the plant computer, tests conducted during feed and bleed l

operations or tests that contained water additions that were not accounted i for in the leak rate calculations, tests.that contained water edditions that were affected by MUT 1evel instrument inaccuracies, and tests where hydrogen was added to the MUT while the test was being conducted. P l

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4 FINDINGS AND CONCLUSIONS ,'

(1) Although leak rate tests were required to be performed tRITy once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, leak rate tests were routinely conducted every,phift, provided the plant computer was available and other shift evolutions did not interfere with the performance of the test.

(2) Because of errors in the procedure, the results of leak rate tests were often erratic, even when tests were run back to back with the same plant conditions.

(3) Most operators had little confidence in the leak rate test that was used to demonstrate conformance with the Technical Specifications. They did not believe that test results were closely coupled with actual plant leakage.

'(4) 'Because of the variability of test results, it was common practice to-run leak rate tests several times per shift until an acceptable result was obtained. Test results frequently showed unidentified leakage in excess of the technical specification limit of 1 gym. The acceptable

.'~ tests would be retained and, contrary to Technical Specification 6.10, the unacceptable tests would be discarded. Some tests were discarded by the CR0s performing the tests and others were discarded by shift foremen and shift supervisors.

(5) Contrary to Admir.istrative Procedure 1012, tests that exceeded the limits of the Technical Specifications were not logged in the Control Room Log. While five of the six shifts routinely logged satisfactory tests,oneshift(shiftA)didnotloganyleakratetests. .

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(6) Contrary to Administrative Procedure 1010, deficiency reports were not

.. .. completed for tests where the results exceeded the acceptance criteria

e. ~? . of the test.

(7) ' Contrary to Technict) Specification 3.4.6.1 and Surveillance Procedure.

2301-301, operators did not enter Action Statement 3.4.6.2.b when leek rate test results indicated unidentified leakage in excess of 1 gpm.

(8) Most operators testified that because the Technical Specifications only required the 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 />, as long as a satisfactory test was obtained during that period, they considered the technical specification satisfied regardless of the number of unsatisfactory test results that were obtained in between.

(9) During a routine inspection of TMI-2 operations on October 18, 1978. an NRC inspector discovered several unsigned, unapproved lenk rate tests lying in the control room. These tests indicated that TMi-2 had been 4.D

- 10 -

f operating for an extended period with unidentified leakage in excess of 1 gpm without entering the action statement. The incident resulted in l Licensee Event Report (LER) 78-62/1T being submitted on November 1, 1978. The LER stated that the incident had occurred as the result of a

" misinterpretation" of the requirements of the Technical Speiifications and that appropriate personnel would be instructed on the reluirements of the applicable sections of the Technical Specifications and the requirement to insnediately invoke applicable action statements when the provisions of the LC0 were not met.

(10) Despite the circulation of the LER to control room personnel and the issuance of a " Supervisor of Operations Memo" addressing the subject, the majority of the operators testified that leak rate test practices did not change. Tests exceeding the limits of the Technical Spect-fications continued to be discarded, and the action statement of the Technical Specifications was not invoked. _

_ . ~

(11)Followingthisincident,someoperatorstestifiedthattheywerein-

~ structed to ensure unacceptable leak rate tests were discarded and not

-1. left lying around the control room where the NRC could find them. Other

~ '

operators testified that they did not recall receiving such an instruc-tion.

(12) Because 6f errors in the procedure and an increase in identified leakage during the months of February and March 1979, it became more and more difficult for operators to get 1eak rate tests results of less than 1 ppm for unidentified leakage. The increased identified leakage to the renctor coolant drain tank was caused by leakage through the PORY and/or -

code safety valves. Identified leakage during this period did not

- exceed the 10 gpm technical specification Itait. .

~

(13) While some operators testified that they felt pressumd to obtain a r.

satisfactory leak rate test as they got closer to the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> limit, all

- of the operators testified that they were nevar directed by shift ~

foremen or shift supervisors to manipulate telt asults. _

(14)vision Based up(on the majority of the operators' testimony, first line (Supervisor of Operations) were aware of the difficulty operators were experiencing to obtain acceptable leak rate test results. One shift foreman believed that higher levels of management knew about these pro-blems, but he could not provide evidence to support his belief.

(15)CRosonthreeofthesixshifts(C,D,andE)testifiedthattheywere aware that hydrogen additions to the MUT could influence leak rate test results and that they personally added hydrogen to manipulate test results. There is strong evidence to indicate that operators on shift B also added hydrogen for this purpose. There is insufficient evidence to conclude that operators on shifts A and F were aware of theihydrogen effect or used this method to manipulate test results.

w--- -

y-se. --. -- -w orw--=~--- -w --w we e--ww- ---w-m.-~,. ,w---------~--w -

1

. l l

' l l .

(16)OperatorsonshiftsDandEalsotestifiedthattheyusedwateraddi- ~

tions to influence the outcome of leak rate tests. An operator on Shift E stated that water was added in small, undetectable amountt"bver the period of the test. An operator on shift D stated that he took.advan-i l

tage of MUT-level transmitter errors while making water addifions to manipulate test results. On the basis of operator testimony and the results of the technical evaluation, them is strong evidence to indi-cate that the other operators on shifts D and E also participated in these practices. There is insufficient evidence to conclude that l

operators on shifts A. B. C. and F used water additions to manipulate l test results.

~

(17) While none of the CR0s who admitted manipulating leak rate test results l by the addition of water and/or hydrogen during tests-testified that they were ordered to do so by their supervisors, there is evidence which

- - indicates that the shift foremen on shifts C and D may have known about -~

1 such practices on their shifts.

[-; (18) On the basis of the technical evaluation, many other tests. involving C all six shifts, are considered invalid as a result of unaccounted-for feed and bleed operations, unstable plant conditions, and the use of i

' ~ inaccurate and unreliable instrumentation to provide input to the plant l

computer during the tests. There is insufficient evidence to prove In

- these methods were intentionally used to manipulate test results.

some cases, for example, these actions resulted in higher calculated leakage than othemise would have been the case. The evidence does support a conclusion that operators did not establish the proper l

' conditions for performing the tests. As long as the test result was -

below the technical specification limit, the test was signed by the .

operator perfoming the test and approved by the shift foresen with little or no review.

'~ - In wunary, it-is apparent from the technical evaluation and operator testimony that many of the practices asscciated with the performance of leak ..

. rate surveillance tests at 1NI-2 violated the Technical Specifications approved plant procedures. This attitude procedural compliance in this area were lax and pemissive.tow personnel.

The leak rate surveillance test was the only method operators had to measure unidentified leakage in order to demonstrate compliance with the Technical Specifications. Because of the variability of the test results, most operators leakage. did not consider the test to be a true measure of act The staff believes that many instances occurred operators were correct.

where leak rate test results were in excess of the technical specification limit, yet, the actual unidentified leakage did not exceed 1 g .

On the basis of operator testimony, when leak rate test results exc'eeded the technical specification limits, a conscious decision was made by' shift supervisors, and possibly management personnel, to disregard the requirements of the Technical Specifications. While direct leak rate mantpiiTation did occur on some shifts. it is apparent that all shif.ts perfome,d -the test with little regard for its validity. If test rte iilts exceeded the technical specification limit, they were discarded and another test conducted. If test results were below the technical specification limit they were retained to satisfy the " administrative requirement." These test results received little or no review regardless of the plant conditions or evolutions in progress that may have rendered the test invalid. These actions, coupled with the lack of confidence in the leak rate test procedure and management's failure to correct test procedure problems and instill high standards for procedural compliance. led to conditions where leak rate tests were conducted in a frivolous manner and where operators were motivated in some cases, to annipulate or falsify leak rate test results. -

oo

.4 ..

4 22 ' .

e 7

e e

- - - - - . - - -----,.---._.--_,._,m,_w _,,,e - , . - - . . - , . ,, ,n ~, -,--,,we--- - - - -- - , - - - - ,

. . /

-4 l

the terms and conditions of their current licenses. NRR did recomend that five operators (01 son Booher 111jes, Congdon, and Miller) be placed in a probationary status until the exg,1 ration of their current licenses and that Iicense renewal be dependent upon continued satisfactory perfomance~ during the probationary period. For Messrs. Olson and Bocher. NRR's recomendations have been rendered moot as a result of their resignation from Waterford 3.

Recomendation As a result of the Comission's Order dated December 18.1985 (CLI 85-18) instituting a hearing on this matter, no Cosnission action is recomended at this time. Pursuant to CLI-85-18 the staff will make recomendations to the Comission subsequent to the Presiding Board's issuance of its. findings of fact. This report is being provided to complete the action required b Commission's staff requirements memorandum (SRN) dated April 2,1984..y,the

~

An unexpurgated version of this report is being provided to the Comission; however, the staff has identified certain portions of this report which should be protected from public disclosure pursuant to the Privacy Act,10 CFR Part 9 and 10 CFR 92.790(a) of the Comission's Rules and Regulations. The staff is currently reviewing this memorandum and its enclosures and is making the required deletions. When the 01 Report is available for public release, copies of the 0! Report and the expurgated version of this report will be provided to the Presiding Board, the parties in the Leak Rate proceeding, the Public Document Room, and the Local Public Document Room.

Original signetir factor Stelle Victor Stello, Jr.

• Acting Executive Director for Operations

Enclosures:

As stated cc: 8. Ha'yes cc w/er. closures 18 2 only:

SECY MC '

0FE

--, ,- .,.-_--_---'-er-

l .

ENCLOSURE 2 CONCLUSIONS AND REC 0fMENDATIONS ON CURRENTLY LICENSED INDIVIDUALS Individual Report Date Tg

i. '.1

• ~

800HER, Raymond R December 14,1984 CONGDON, Joseph R. May 30, 1985 3 December 3, 1984 5

. COOPER, Martin V.

October 15,1985 (Supplement)

FAUST, Craig C. May 30, 1985 7 FREDERICK, Edward R. May 30, 1985 9 E

'~

GUTHRIE, Carl L. October 8, 1985 11 August 20, 1985 13 ILLJES, Theodore F.

MCGOVERN, Hugh A. Jr. October 4, 1965 15 17 1

~

MILLER, Adam W. September 6, 1985

. . .. . 20 OLSON, Dennis 1. December 14,1984

"'.~ ..

• Recently resigned.

i l

l NOTE: This enclosure discusses information that is the subject of an ongoing 01 investigation and information that isThis maintained enclosureinmay thenot NRC s Privacy Act System of Records (NRC-16)dination.with NRR and the be disseminated outside the NRC without coor permission of the ED0 or the Director. 01. Internal 'ascess and distribution should be on a "need-to-know" basis. ,

+C,

. . . . - - - - , _ _ _ . - ,- .,_.-,n, _ . - _ . . , _ . - - , --

. 1 RAYM0ND R. BOOHER ,

Current Position: No longer licensed. Mr.BooherresignedfrEiLouisiana Power and Light Company on July 26, 1985. Before.his resignation, Mr. Bocher was a Control Room Supervisor (SRO) at Waterford Unit 3. 'I Preaccident Position at TMI-2: Control Room Operator (RO) on Shift "E."

Other Individuals on Same Shift at TMI-2:

Shift Supervisor: Bernie Smith Shift Foreman: Ken Hoyt Control Room Operators: Harold Hartman John Blessing (in training)

Past Involvement in Leak Rate Testing Irregularities: ]

During the period under investigation, Mr. Bocher was involved in actions that violated approved plant procedures and were contrary to the THI-2 Technical Specifications. These actions included: failure to ensure that leak rate surveillance tests were conducted in accordance with the approved plant procedures; failure to properly review the results of leak rate surveillance tests; failure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the limiting conditions for operation, specified in the Technical Specifications, were exceeded; and failure to retain test results that exceeded the limits of the Technical Specifications.

Despite Mr. Booher's dental that he was not involved in leak rate test manipulation, the weight of evidence, including the technical evaluation of-leak rate tests performed by Mr. Booher and the testimony of Messrs. Hartman and Blessing, strongly suggests that Mr. Booher was involved in the

! manipulation of leak rate test results by adding hydrogen and water to the makeup tank during leak rate tests. -

Current Performance: _ _

Mr. Booher appeared to be a confident, dedicated operator, who was very familiar with the procedures and operating principles necessary to safely op-erate Waterford 3. He stated he is thoroughly comitted to the safe operation  ;

of the plant. He indicated that he expects complete candor from himself and his co-workers in all matters relating to the operation of the plant and would not tolerate a lesser standard from his subordinates. .

Interviews with Mr. Booher's supervisors l

l

i 2-RAYMONDR.800HER(CONTINUED) .

~

NRR Conclusions and Recomendation: j '

It appears that Mr. Booher has eined a great deal, of experienha s'ince his termination with GPU. At the t me of his interview, Mr. Booh'e'r~ understood his duties and responsibilities for the safe operation of Waterford 3 and was comitted to following the approved procedures and operating principles necessary to carry out those responsibilitias.

No enforcement action was recommended against Mr. Booher. Rather, NRR recomended that -he be placed in a probationary status until the expiration dateofhiscurrentSR0 license (March 1,1986). The renewal of Mr. Booher's

- license would have been dependent on a satisfactory evaluation by both the licensee and the NRC of his perfomance during the probationary period. -- -

This recommendation has been rendered soot because Mr. Bocher is no longer a licensed operator.

Stier Report

Conclusions:

The Stier Report does not reach conclusions regarding Mr. Booher because he is no longer employed within the GPU system.

S

. e s . .

JOSEPH R. CONGDON

' l Current position: Shift Foreman (SRO). TM1-2. [ .

l preaccident position at 1MI-2: ControlRoomOperator(RO)on-thift*C." ..

Other Individuals on Same Shift at TMI-2:

Shift Supervisor: Brian Mehler Shift Foreman: Chuck Adams Control Room Operators: Marty Cooper Mark Phillippe (in training) past involvement 'in Leak Rate Testing irrecularities:

During the period under investigation. Mr. Congdon was involved in actions . ~

that' violated approved plant procedures and were contrary to the TMI-2 Technical Specifications. These actions included: failure to ensure that '

- leak rate surveillance tests were conducted in accordance with the approved

.; plant procedures; fathre to properly review the results of leak rate surveillance tests; fauure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the

~

limiting conditions for operation, specified in the Ta'chnical Specifications.

~

were exceeded; and failure to retain test results that exceeded the limits of the Technical Specifications.

Mr. Congdon did not consider hydrogen additions to the makeup tank during leak rate tests to be a violation of the procedure. He admitted adding l

hydrogen to the makeup tank during leak rate tests with the intent of

- influenciro test results. . -

c- . .

Current performance:

He Mr. Congdon appeared to be a very conscientious, dedicated operator.

seemed to be sincerely committed to operating the plant safely and in accordance with all procedures and regulations. During the interview, he displayed a quiet, confident attitude and always seemed to logically think through any situation in which he was placed. He demonstrated a thorough knowledge of plant procedures and technical specifications and his answers reflected a significant amount of operational experience. The overall impression was that of an experienced operator who used good operating .

practices on a daily basis. ' -

f

1 l

1 l

4-JOSEPHR.CONGDON(CONTINUED)

Current Performance (continued): .

The NRC resident inspectors were also familiar with Mr. Congdon!

NRR Conclusions and Recommendation:

Mr. Congdon is now willing to admit his involvement in activities that were wrong. He recognizes the seriousness of these activities and is willing to accept responsibility for his actions.

it is apparent that he has learned from his past mistakes and--has subsequently developed a more thorough understanding of his duties and

- responsibilities as a licensed senior reactor operator. He does understand g, his duties and responsibilities for conducting safe operations at THI-2 and is committed to following the approved procedures and operating principles necessary to carry out these responsibilities.

' NRR recommended that no enforcement action l be taken against Mr. Congdon. Rather NRR reconnended that he be placed in a probationary status until the expiration date of his current SRO license (January 22,1986). The renewal of Mr. Congdon's license at that time would 1 -

be dependent on continued satisfactory performance during the probationary-period as evaluated by both the licensee and NRC.

g, -

- Stier Report

Conclusions:

Analysis of employee testimony, leak rate tests, and related plant documents suggests that Mr. Congdon failed to properly utilize the leak rate test for the purpose of measuring reactor coolant system (RCS) leakage and also failed to take required action in response to indications of excessive RCS leakage I

in October 1978 and January and March 1979.

1 Mr. Congdon himself admitted that he knowingly engaged in the manipulation of leak rate tests while performing as a CR0 at TMI-2 by adding hydrogen to the makeup tank. Furthermore, his testimony, together with plant records, implicates others on his shif t in the same practice.

O d e

~ - - - , - , - - , m ,- , - - - - - -

-m n ~

- 5

.~

I MARTIN V. COOPER '

i Control Room Supervisor (SRO) San Onofre' Units 2/3.

Current Position:

Preaccident Position at TMI-2: Control Room Opera, tor (RO) on Shift 'C."

q..

Other Individuals on Same Shift at TMI-2:

j Shift Supervisor: Brian Mahler '

Shift Foreman: Chuck Adams Control Room Operators: Joseph Congdon MarkPhillippe(intraining)

Past involvement in Leak Rate Testino Irregularities:

- During the period under investigation. Mr. Cooper was involved in actions / .

~

- -that violated approved plant procedures and were contrary to the TMI-2 Technical Specifications. These actions included: failure to ensure that,.

leak rate surveillance tests were conducted in accordance with the approved

. ?- plant procedures; failure to properly review the results of leak Control Room Log; failure to take the required followup action when the limiting conditions for operation, specified in the Techni.cal Specifications.

• were exceeded; and failure to retain test results that exceeded the limits of the Technical Specifications.

- Mr. Cooper admitted adding hydrogen to the makeup tank during leak rate tests; however, he denied that is was done with the intent of manipulating the outcome of the test. According to Mr. Cooper, if hydrogen pressure was

.Iow in the operating band during periods in which If the leak test rate surveillance results were tests were being run, he would add hydrogen.

acceptable, Mr. Cooper would retain the test knowing its results may have

.-- been influenced by the addition of hydrogen. Despite Mr. Cooper's denial that he intentionally manipulated leak rate tests, the weight of the evidence, including technical evaluation of leak rate tests conducted by Mr.

Cooper and the testimony of Mr. Congdon, strongly sggest . that Mr. Cooper" ~

was involved in intentional manipulation of leak rate tests by adding

" - hydrogeri to the makeup tank.

I j Current Performance:

Mr. Cooper appeared to be a very conscientious and knowledgeable operator.

His comitment to operate the plant safely and in accordance He demonstrated with aallthorough ,

procedures and regulations seemed to be sincere.

l knowledge of plant procedures and technical specifications and the ability to use them. He presented himself as a forceful supervisor, willing to direct I

subordinates, accept responsibilities for his own actions. and get things done on his shift. .

e m

• g e g

l

. i

. 1 MARTINV. COOPER (CONTINUED)

Current Perfomance (continued): [ .

NRR Conclusions and Recomendation:

. . . , _ , . While Mr.

- Cooper has admitted his involvement in improper activities. it appears clear

,i .

from his interviews that he now knows these actions were wrong and has subsequently developed a much more thorough understanding of his duties and

> responsibilities as a licensed operator.

Based on all of the information known to date _ , ,

NRR recomended'that no enforcement action be taken against Mr. Cooper.

5 tier Report

Conclusions:

The Stier Report does not reach conclusions regardiag Mr. Cooper because he

, . . - '- is no longer employed within the GPU system.

e i

W I

CRAIG C. FAUST .

Current Position: Instructor IV. Training Department GPU Nuc.lsar Corporation. Holds an SRO license on TMI-2. -

Preaccident Position at TMI-2: Control Room Operator (RO) on Shift "A."

Other Individuals on Same Shift at TMI-2:

Shift Supervisor: William Zewe Shift Foreman: Fred Scheimann Control Room Operator: Ed Frederick Past Involvement in Leak Rate Testing irregularities: .

During the period under investigation, Mr. Faust was involved in actions th_at

- violated approved plant procedures and were contrary to the TMI-2 Technical Specifications. These actions included: failure to ensure that leak rate surveillance tests were conducted in accordance with the approved plant procedures; failure to properly review the results of leak rate surveillance l

- tests; failure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the limiting conditions for  ;

operation, specified in the Technical Specifications, were exceeded; and  !

failure to retain test results that exceeded the limits of the Technical Specifications.

! Mr. Faust denied that he personally ritempted to influence or manipulate the outcome of leak rate test results by the addition of water and/or hydrogen to the makeup tank during the tests. Mr. Faust also denied that he had personal knowledge of, or was aware of other operators intentionally manipulating leak rate surveillance tests. While some of Mr. Faust's actions regarding the conduct of leak rate surveillance testing were contrary to the Technical

- Specifications and written procedures, the technical analysis of leak rate

surveillance tests supports a finding that Mr. Faust did not intentionally

( perfonn evolutions that would improperly influence the outcome of leak rate -

tests. .

Current Performance:

l Mr. Faust appeared to be a very conscientious and dedicated operator. '

Although he is an instructor in the Training Department, he showed confidence and appeared to be comfortable discussing shift operations. He was very knowledgeable of the plant and plant procedures, both from a classroom and from an operational aspect. Overall, he appeared to strive to operate safely and in accordance with all applicable procedures.

'~

Mr. Faust's supervisors l

3 CRAIG C. FAUST (CONTINUED) .

NiiR Conclusions and Recomendation: [

Mr. Faust has admitted he was involved in some activities assch.jated with leak rate testing which were contrary to approved" plant procethres and technical specifications. However, he denies that he was invoTved in leak rate test manipulation or had knowledge that such actions occurred. The technical evaluation of leak rate tests involving Mr. Faust tends to support his statement that he was not personally involved in leak rate test falsification. Based on the consistency of his testimoty with subsequent technical evaluation and plant records, his statements concerning lack of knowledge of other operators' actions to influence leak rate testing is credible. .

- It cppears that Mr. Faust has gained a great deal of experience during the .

(

t .-

.past.6 years. Mr. Faust does understand his duties and responsibilities- for conducting safe operations at TMI-2 and is comitted to following the approved procedures and principles necessary to carry out those responsibilities. .. _

. Based on all of the information known to date. MRR concluded that there is

' reasonable assurance that Mr. Faust has and will continue to fulfill the terms and conditions of his current senior reactor operator license. NRR recomended that no enforcement action be taken against Mr. Faust for his past involvement in improper activities associated with preaccident reactor coolant system leak rate surveillance testing at TMI-2.

I

~

5 tier Report

Conclusions:

I Analysis of employee testimony, leak rate test records, and related plant c,

documents, suggests that Mr. Faust failed to properly utilize leak rate tests for.the purpose of measuring reactor coolant system leakage and also failed.,

to take required action in response to indications of excessive leakage 1_n -

October 1978 and January and March 1979.

There is not sufficient evidence to support a conclusion that Mr. Faust knowingly added water or hydrogen during leak rate tests in order to manipulate test results.

.g.

EDWARD R. FREDERICK Current Position: Instructor V. Corporate Training Division. fapU Nuclear j

Corporation. Holds an SRO license on THI-2. .

! ~

.Q Preaccident Position at TMI-2: ControlRoomOperator(RO)onShift"A."

Other Individuals on Same Shift at TMI-2:

' Shift Supervisor: William Zewe Shift Foreman: Fred Scheimann Control Room Operator: Craig Faust i

Past involvement in Leak Rate Testino Irregularities:

~

During the period under investigation. Mr. Frederick was involved in actions that violated approved plant procedures and were contrary to the THI-2 i.

Technical Specifications. These actions included: failure to ensure that leak rate surveillance tests were conducted in accordance with the approved plant procedures; failure to properly review the results of leak rate surveillance tests; failure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the limiting conditions for operation, specified in the Technical Specifications, l

were exceeded; and failure to retain test results that exceeded the limits of the Technical Specifications.

The technical analysis tends to support Mr. Frederick's testimony that he did not intentionally add water and/or hydrogen to the makeup tank during leak rate tests for the purpose of manipulating test results. However, other aspects of his testimony dealing with difficulty in obtaining satisfactory, test results, the disposition of unsatisfactory results, and his overall knowledge of leak rate testing irregularities raise questions regarding the

- accuracy of his responses during the interview.

Curr'ent Performance: ,

Mr. Frederick appeared to be a sincere, conscientious and dedicated operator.

Although at times he seemed hesitant in his answers, this hesitation appeared to have been the result of careful consideration of each question and his j answer. Although his primary duty involves training, he was very j

knowledgeable of shift operations. He generated an overall impression of great sincerity and as someone who naturally accepts complete responsibility for his actions.

Mr. Frederick's supervisors ,

4

,e.~.-- -

e .. - -, , , --n--, . , . _ . , , . , - , _ _. . , , - - - - -._ ,,,,,-, ,- -

EDWARD R. FREDERICK (CONTINUED) .

MRR Conclusions and Recommendation: ~

During the period Mr. Frederick was a licensed control room operator at TMI-2 before the accident, he stated that he was neither involved 147 nor had knowledge of. leak rate testing practices that were contrary to approved

Mr. Frederick also denied plant procedures and Technical Specifications.that he was involved t of such actions. While the technical analysis tends to support his testimony that he did not intentionally add water and/or hydrogen.to the makeup tank during leak rate tests for the purpose of manipulating test results, other -

aspects of his testimony dealing with the difficulty in obtaining satis-factory test results, the disposition of unsatisfactory resulte s, and his overall knowledge of leak rate testing irregularities raise questions'-re-

- garding the accuracy of some of his responses during the interview. -

~ . MRR concluded that Mr. Frederick does pf-derstand his duties s'nd responsibilities for conducting safe operations at

-

• TMI-2 and that he is committed to following approved procedures and prin-

- ciples necessary to carry out those responsibilities.

t .

While the accuracy of some of Mr. Frederick's statements regarding leak rate NRR testing irregularities is suspect. NRR was unable to prove that he lied.

concluded that he was not personally involved in leak rate surveillance test

(

manipulation or falsification.. NRR concluded that there is reasonable assurance t Mr. Frederick has and will continue to fulfill the terms and conditions his current Senior Reactor Operator license. MRR reconnended that no enforcement action be taken against Mr. Frederick for his past involvement in

• ~

improper activities associated with preaccident reactor coolant system l

~ rate surveillance testing at THI-2.

~

- Stier Report

Conclusions:

Analysis of employee testimony. leak rate test records, and related plant documents, suggests that Mr. Frederick failed to properly utilize leak rate tests for the purpose of measuring reactor coolant system leakage and also failed to take required action in response to the indications of excessive RCS leakage in October 1978 and January and March 1979.

There is not sufficient evidence to support a conclusion that Mr. Frederick knowingly added water or hydrogen during leak rate tests ..- to manipulate test results. .

e

i I

CARL L. G'JTHRIE ,

l Current Position: Foreman, Radwaste Operations THI-2. Holds.An SRO license on TMI-2. i

.3 Preaccident Position at TMI-2: Shift Foreman'(SRO) on Shift "F."

4 Other Individual on Same Shift at TMI-2:

Shift Supervisor: Ken Bryan Control Room Operators: Hugh McGovern Earl Hamila i 4

Leonard Germer (in training)

Past Involvement in Leak Rate Testing Irregularities:

~

- -During the period under investigation, Mr. Guthrie was involved in actions-as a Shift Foreman that violated approved plant procedures and were contfary '

to the TMI-2 Technical Specifications. These actions ir.cluded: failure to

ensure that leak rate surveillance tests were conducted in accordance with l

the approved plant procedures; failure to ensure that all leak rate tests were properly recorded by control room operators in the Control Room Log; failure to properly review the results of leak rate surveillance tests; fail-ure to retain leak rate test results that exceeded the limiting conditions of operation of the Technical Specifications; and failure to take the required followup action when the limiting conditions for operation, specified in the Technical Specifications, were exceeded. a Despite these actions Mr. Guthrie denies that he was involved in or was

, knowledgeable of any activities on the > art of operators or supervisors to intentionally influence or manipulate tte outcome of leak rate test results'.

i

- - Current Performance:

e In general, Mr. Guthrie appeared to be a cautious operator with a satis-factory knowledge of operating procedures and administrative requirements-in effect at THI-2. He demonstrated excellent , judgment when placed~in hypo-l thetical situations that did not have clearly correct solutions. In those areas in which he demonstrated some weaknesses, it was apparent that he would readily admit to such lack of knowledge and seek assistance from more knowl-edgeable operators. He expressed a comitment to strict compliance with procedures, and his responses during the ' interview indicated that all his I

actions on shift would be based on strict procedural compliance.

l The overall impression of Mr. Guthrie was that he is an average operator.

l somewhat lacking in confidence, but with the comon sense to request assist-ance when necessary. The background interviews l

l

12-CARLL.GUTHRIE(CONTINUED) ,

NRR Conclusions and Recommendation:

There is insufficient evidence to conclude that Mr Guthrie up. involved in leak rate test manipulation; however, the evidence supports a Yinding that Mr. Guthrfe was grossly negligent in his duties as a Shift Foreman with respect to supervising leak rate surveillance testing and initiating required followup actions. NRR concluded that Mr. Guthrie approved and submitted test results without regard for their validity, as long as the calculated uniden-tified leakage was below the technical specification limit. In some cases he knowingly violated the technical specifications by failing to enter the action statement when leak rate test results exceeded the limiting condition for operation. -

~

NRR.

. concluded that Mr. Gu'thrie has learned from his past sistakes, does under -

stand his duties and responsibilities for conducting safe operations at -

TMI-2, and that he is comitted to following approved procedures and prin-ciples necessary to carry out those responsibilitics. Me imparts this same

-= sense of responsibility to his subordinates.

~

• TMI-2.

Based on all of the infonnation known to date .

~~

NRR recomended that oc enforcement action be taken against Mr. Guthrie.

Stier Report

Conclusions:

Analysis of employee testimony. leak rate tests, and related plant documents reveals that Mr. Guthrie failed to properly supervise the performance of leak r.

~

rate tests t.nd also failed to ensure that required action was taken in response to indications of reactor coolant system leakage during October 1978 and March 1979. There is insufficient evidence to support a conclusion that Mr. Guthrie participated in, or knowingly tolerated, manipulation of leak' rate test results.

=.m qk.'

i THEODORE F. ILLJES

! Current Position: Shift Supervisor TMI-2 (SRO).

Preaccident Position at THI-2: Control Room Operator (RO) on Shift "B." l 1

Other Individuals on Same Shift at TMI-2:

Shift Supervisor: Joe Chwastyk Shift Foreman: Bill Conaway Control Room Operators: John Kidwell ChuckMell(intraining)

Past Involvement in Leak Rate Testing Irrecularities:

During the period under investigation, Mr.1113es was involved in actions -

that violated approved plant procedures and were contrary to the TMI-2 Technical Specifications. These actions included: failure to ensure that--

leak rate surveillance tests were conducted in accordance with the approved plant procedures; failure to properly review the results of leak rate surveillance tests; failure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the limiting conditions for operation, specified in the Technical Specifications, j t

were exceeded; and failure to retain test results that exceeded the limits of the Technical Specifications. ,

Mr.111jes denies that he performed evolutions with the intent of influencing the outcome of leak rate test results. Based on the weight of.the available evidence, including the high number of invalid or questionable tests involving Mr.111jes and the testimony of his former Shift Supervisor 4

(Mr. Chwastyk), it appears that either Mr.111jes was not truthful regarding

) his knowledge of or involvement in leak rate test manipulation, or he was grossly negligent in that he would knowingly acce at test results less than

~

the technical. specification limit regardless of tie evolutions in progress du' ring the test.

l -

Current Performance: ,

l ,

Mr.111jes appeared to be a very conscientious and dedicated operator. He seemed to be sincerely committed to operating the plant safely e.nd in accordance with all procedures and regulations. He demonstrated a very cautious, measured approach to plant operations. He also demonstrated a f thorough knowledge of procedures and technical specifications and the ability to use them. When placed in postulated situations not covered by procedures, ,

he displayed good judgment in his choice of actions and was quick to consult with management and the NRC to resolve problems. His highest priority appeared to be ensuring that all evolutions conducted on his shift were done properly and in accordance with approved procedures.

\

14 THEODOREF.ILLJES(CONTINUED) .

Current Performance (continued): ~

4 .

WRR Conclusions and Recomendation:

During the period Mr.111jes was licensed as a control room operator at TMI-2 before the accident, 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. Mowever; he denies that he was involved in leak rate test manipulation or knowledge-of such actions. The weight of available evidence. including statements by his former Shift Supervisor (Mr. Chwestyk) and the technical analysis, strongly

""- suggests that Mr.111jes was either not truthful in answering questions

. regarding his role in, or knowledge of. leak rate test manipulation, or he was grossly negligent in perfoming leak rate tests.

. NRR concluded Mr.1113es does understand his duties and respon'sibilities for conducting safe operations at TMI-2 and

- he is comitted to following approved procedures and principles necessary to carry out those responsibilities. .. . . . . . .

i -

..- In sumary, while the accuracy of some of Mr.111jes' statements regarding l C.~ leak rate testing irregularities is suspect. NRR was unable to prove that he lied, NRR concluded that he any have been involved in, or had knowledge of leak rate test manipulation. Mowever, based on all of the information known

~

I NRR reconnended that no enforceinent action be 'taken against Mr.111jes at this time. Rather. NRR recomended that he be placed in a probationary status until the expiration date of his currentSR0 license (April 2.1986). The renewal of Mr. 111jes' license at that time would be dependent on continued satisfactory perfomance during th'e probationary period as evaluated by both the licensee and NRC.

Stier Report

Conclusions:

leak rate test records, and W1sted plant Analysis of employee testimony,1jes documents indicates that Mr. 11 did not properly utilize itak rate tests for the purpose of measuring reactor coolant system leakage arid did not take required action in response to the indications of excessive 16skage. There also is strong circumstantial evidence that Mr. 111jes knowingly added hydrogen during leak rate tests in order _to manipulate test results.

15-HUGH A. MCGOVERN JR. ,

Current position: plant Operations Manager TMI-2. HoldsanMR0licenseon TMI-Z. "

preaccident position at TMI-2: ControlRoomOperator(RO)onShift*F.*

Other Individuals on Same Shift at TMI-2:

Shift Supervisor: Een Bryan Shift Foreman: Carl Guthrie

' Control F.oon. Operators: Earl Hasnila LeonardGarner(intraining) -

- past involvement in Leak Rate Testino irrecularities: ..

' During the period under investigation. Mr. McGovern was involved in actio$

that violated approved plant procedures and were contrary to the TMI-2

- Technical Specifications. These actions included: failure to ensure that

""- leak rate surveillance tests were conducted in accordance with the approved plant procedures; failure to properly review the results of leak rate surveillance tests; failure to properly record all leak rate tests in the

- Control Room Log; failure to take the required followup action when the limiting conditions for operation, specified in the Technical Specifications, were exceeded; and failure to retain test results that exceeded the limits of the Technical Specifications.

Mr. McGovern agrees in retrospect that many of his actions involving leak rate surveillance testing at TMI-2 violated approved plant procedures and :

i were contrary to the TMI-2 Technical Specifications. Because of problems with instrumentation and the procedure itself. Mr. McGovern considered the test " meaningless" as far as representing true plant leakage. As a result.

C the test was treated as an administrative requirement only. He denies that he was involved in intentional leak rate test manipulation. From the -

technical evaluation of leak rate tests involving Mr. McGovern, there is insufficient evidence to conclude that any of these tests were intentionally manipulated. However, based on Mr. McGovern's attitude towards the test at the time. it appears he did not attempt to establish the proper steady-state conditions required for the test. If the test result was greater than the technical specification limit, the test would be discarded and another test would be started. If the test result was less than the technical specifi-cation limit, he would retain it with little or no review to ensure it was a valid test.

Current Performance: ...

~

In general. Mr. McGovern appeared to be a very confident, knowledgeable, and cooperative operator. He seemed to be comfortable proposing solutions or actions for tie various hypothetical situations which were presented to him.

In all instances he followed a safe, conservative, yet practical course of action. At all times, he appeared connitted to operating the plant in

16-i HUGHA.MCGOVERNJR.(CONTINUED) -

Current Performance (continued): T accordance with approved operating procedures and, sound operatLing principles.

He demonstrated a thorough knowledge of plant procedures and technical specifications, and was particularly knowledgeable of administrative require-Th's overall impression was that Mr. McGovern was a ments and procedures.

very experienced, highly competent, aggressive senior operator, comitted to performing his duties in accordance with good operating'oractices.... . ,

NRR Conclusions and Recomendation:

f -

During the period under investigation. Mr. McGovern admitted he was involved l "

-in activities associated with reactor coolant system leak rate testing that -

were in violation of approved plant procedures and 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 in leak rate test manipulation; however, the evidence supports a finding that

- Mr. McGovern was grossly negligent in his duties as a control room operatorBa with respect to leak rate surveillance testing.

. that the test was a meaningless administrative requirem without regard for their validity as long as the calculated unidentified leakage was below the technical specification limit. ~

NRR con-cluded that Mr. McGovern has learned from hls past mistakes, does inderstan

' his duties and responsibilities for conducting safe operations at THI-2 and

, . - that he is comitted to following approved procedures He imparts and principles this same senseneces-of

% sary to carry out those responsibilities. .. .

responsibility to his subordinates.

In sumary, based on all of the information known to date and balancing Mr. McGovern's past improper actions at TMI-2, against his subsequent excellent performance. NRR recommended that no enforcement action be take against Mr. McGovern.

Stier Report

Conclusions:

Analysis of employee testimony, leak rate test records, and related plant documents suggests that Mr. McGovern failed to properly utilize leak rate tests for the purpose of measuring reactor coolant sys There is not sufficient reactor coolant system leakage in March of 1979.

evidence to support a conclusion that Mr. McGovern knowingly added water or hydrogen during leak rate tests in order to manipulate test results.

l 1

ADAM W. MILLER ,

• Current Position: Manager Plant Operations TMI-2. He holds 'ankRO license on TMI-z. -

T preaccident Position at TMI-2: Shift Foreman (SRO)'on Shift *D7 Other Inttividuals on Same Shift at TMI-2:

Shift Supervisor: Greg Hitz '

Control Room Operators: Dennis Olson Mark Coleman ly m Wright Past Involvement in Leak Rate Testing irregularities:

.During the period under investigation. Mr. Miller was involved in actions as a Shift Foreman that violated approved plant procedures and were contrary to the TMI-2 Technical Specifications. These actions included: failure to 3 __ ensure that leak rate surveillance tests were conducted in accordance with

~'

the approved plant procedures; failure to ensure that all leak rate tests were properly recorded by control room operators in the Control Room Log; failure to properly review the results of leak rate surveillance tests; j

. failure to retain leak rate test results that exceeded the limiting i conditions of operation of the Technical Specifications; and failure to take the required followup action when the lia.iting conditions for operation.

J - specified in the Technical Specifications,. were exceeded.

Mr. Miller 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. Mr. Miller was aware that is i

Shift Foreman it was his responsibility to ensure his shift's compliance with i

the Technical Specifications. Mr. Miller also agrees that there is strong O evidence. including the testimony of Mr. Coleman, to indicate operators on .

his shift were perfoming actions that were contrary to intent and/or spirit of the leak rate test surveillance procedure and that these actions were frone with the intent of influencing or manipulating the outcome of leak rate - '

surveillance tests. Nevertheless. Mr. Miller states that before the accident he had little involvement in the performance of leak rate tests and had no involvement in or knowledge of operators on his shift intentionally manipulating the outcome of test results.

The results of the technical analysis indicate that of the six shifts standing watch during the last 3 months of operation of 1MI-2. Shift "D" had the highest percentage (931) of " questionable" leak rate tests. The vast majority of these questionable tests show water additions to the makeup tank during the last few minutes of the test, resulting in a calculated leak rate that was smaller than the actual leak rate. Despite conflict h s testimony by the three CR0s as to why the water additions were made., the weight of the evidence would indicate that these additions were made to intentionally influence the outcome of leak rate surveillance tests. While Mr. Miller was not directly involved in the actual conduct of the tests and his statements

- 18-ADAMW. MILLER (CONTINUED) .

Fast involvement in Leak Rate Testing irregularities (continued)i -.

that he did not order or direct the manipulation of tests are credible and are supported Mr. by theunaware Miller was operators' testimony, that leak it does rate nottest appear taking place on manipulations were'a his shift.

Current Performance: f i

In general. Mr. Miller appeared to be a cautious, conservative operator.

intent on ensuring that the stated actions would be in conformance with approved procedures and operating principles. Although somewhat hesitant in 4

response to some of the hypothetical situations overall he seemed very knowledgeable of the requirements of the operating procedures. TMI-2 Technical Specifications, and the facility administrative requirements. N_e' also appeared to be comitted to operating the plant in accordance with .

approved operating procedures and sound operating principles and requiring

~

the same compliance from his subordinates. Overall Mr. Miller seemed to be a highly competent, cautious, and dedicated senior operator uho would take

" those actions necessary to ensure that plant evolutions were conducted safely

! and in full compliance with clant and NRC requirements. _.

)

i NRR Conclusions and Recomendation:

During the period under investigation, while Mr. Miller served as the Shift Foreman at THI-2 for Shift "D." 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.

However Mr. Miller denies that he was involved in or was knowledgeable of -

- other actions on the part of his CR0s to intentionally The influence or weight of available manipulate the outcome of leak rate test results. evidence. including technical analysis, strongly suggests that Mr. Miller was either not truthful in answering questions regarding his knowledge of these activities or he was grossly negligent in his duties as Shift Foreman with respect to leak rate surveillance tests.

MRR concluded that Mr. Miller has learned from his past mistakes, does understand his duties and responsibilities for conducting safe operations at TMI-2. and is committed to following approved procedures and principles _pecessary to carry out those responsibilities. He imparts this same sense of '" " '

responsibility to his subordinates. ... . . . .

_ , . _ _ . . . - . ,,.--..g, _ - _ _ _ , ._ _ . , , . _ . ~ ..-__.,._m,,, .- _ _ - _ - - . - - , _ - - _ . . _ _ _ _ . . -_

. 19 ADAM W. MILLER .

i NRR Conclusions and Recommendation (continued):

In sumary, based on all of the infomation known.to date

~

~

NRit r'e commended that enforcement action not be taken against Mr. Miller at this time. Rather. NRR recomended that he be placed in a probationary status until the expiration date of his current SRO license (September 1.1986). The renewal of Mr. Miller's license at that time would be dependent on continued satisfactory performance during the probationary period as evaluated by both the licensee and the NRC.

Stier Report

Conclusions:

Analysis of employee testimony. leak rate test records, and related plant documents reveals that Mr. Miller failed to properly supervise the perfomance of leak rate tests and also failed to ensure that required act4on was taken in response to indications of reactor coolant system leakage during October 1978 and January 1979. There is insufficient evidence from which m

~

conclude that Mr. Miller participated in, or knowingly tolerated.

manipulation of leak rate test results.

.p l - .

.O M

l l

l . ._ _ _..

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I DENNIS 1. OLSON .

Current Position: Mo longer licensed. Mr. Olson resigned fros Louisiana '

f Power and Light Compan on June 28, 1g85. prior to his res gnstion, l Mr. 01 son was a Contro RoomSupervisor(SRO)atWaterford ig3.-

Preaccident Position at TMI-2: ControlRoomOperator(R0)onSh'ift"D.*

Other Individuals on same shift at THI-2:

Shift Supervisor: - Greg Mitz Shift Foreman: Adam Miller Control Room Operators: Mark Coleman Lynn Wright .

- past involvement in Leak Rate Testing Irrecularities: -

During the period under investigation, Mr. Olson was involved in actions.that violated approved plant procedures and were contrary to the TMI-2 Technical

~ Specifications. These actions included: failure to ensure that leak rate surveillance tests were conducted in accordance with the approved plant O- procedures; failure to p perly review the results of leak rate surveillance l .

tests; failure to roper y record all leak rate tests in the Control Room Log; failure to ta e the required followup action when the limiting con-I ditions for operation, specified in the Technical Specifications, were exceeded; and failure to retain test results that exceeded the limits of the Technical Specifications.

j I Throughout the interview Mr. Olson did not appear to answer key questions in a straightforward or candid manner. The majority of his responses concerning

~ the conduct of leak rate surveillance tests after the October 18, 1978 inct-dent resulting in LER 78-62/1T are inconsistent with the testimony of his

• Shift Forenan and the other CR0s on his shift. In addition, his dentals that

"~ he participated in or was aware of leak rate tcst manipulation are inconsis-tent with the testimony of Mr. Coleman, who stated that hydrogen and water were added to the makeup tank on their shift in order to manipulate the . "

outcome of leak rate tests. The technical evaluation of leak rate tests performed on shift *0" supports Mr. Coleman's testimony and not Mr. 01 son's.

Current Performance:

Mr. 01 son appeared to be a dedicated, conscientious operator. During the interview, he was at times hesitant and somewhat uncertain as to the details of some of the Waterford administrstive procedures and seemed to lack some self-confidence. Mowever, there was nothing in his responses to indicate he could not be relied on to operate the plant competently and reliably, or that he was not cemitted to operating in accordance with approved operating procedures and sound operating principles, He indicated that-he believed in complete candor with respect to plant operations.

~ .

DENNIS 1.OLSON(CONTINUED) -

! Current Perfomance (continued): .

I a

NRR Conclusions and Recommendation:

During the period that Mr. Olson was licensed as a Control Room Operator at TMI-2 before the accident, he admitted he was involved in some activities -18, 1978 associated LER incident.

with leak rate testing irregularities until the OctoberHow Teak rate test irregularities, including test manipulation or falsification.

The weight of evidence, including statements by Mr. Coleman and the results-of the technical evaluation of Mr. 01 son's leak rate tests, strongly suggests that Mr. Olson was not truthful in answering questions regarding leak rate test manipulation.

the facts differ from other evidence are:

(1) that he never threw away unsatisfactory leak rate test results following the October 18, 1978 incident (2) that he ogerated TMI-2, without violating Technical .imiting5)ecification 3.4.6.2, Reactor Coolant System Operational Leakage l Condition for Operation" that he was not aware that hydrogen additions to the makeup tank (3) could alter makeup tank level indication and consequently influence leak rate test results in a favorable maniser (4) that he was not aware that water additions to the makeup tank late in the test could produce the same effect on leak rate test results as hydrogen additions That he never added water to the makeup tank for the purpose of (5) altering leak rate test results

- 22-DENNIS 1. OLSON NRR Conclusions and Recomendation (continued):

While NRR believes that Mr. Olson was not truthful in some of Ais-answers t questions involving his past actions at TN!-2, NRR concluded 'that Mr. Olson does understand his duties and responsibilities for the safe operation of Waterford 3 and that he is comitted to following the approved procedures and operating principles necessary to carry out those responsibilities. . ... _ _ _ . . .

Rather, it was No enforcement action was recomended against Mr. Olson.

recomended that he be placed in a probationary status until the expiration dateofhiscurrentSR0 license (November 17,1985). The renewal of Mr. -

~~.

_ ~ 01 son's license at that time would have been dependent on continued satisfactory performance during the probationary period as evaluated by both the licensee and NRC.

This recousnendation has been rendered moot because Mr. Olson is no longer a licensed operator.

j ,

Stier Reoort

Conclusions:

The Stier Report does not reach conclusions regarding Mr. 01 son because he is not longer employed within the GPU system.

e i . .-

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9 I

I M

D e-n---- - + , , . - , ---,,,,,,._,-.--,,.,np,,-gn.._,..-.--.,--_ - . , . _ . .m.,,____ _ - , , - - - - - - _ - - _ _ - _ _ _ . . . _ . --

Enclosure 3 UNITED STATas ,

[ e, NUCLEAR REGULATORY COMMISSION s  ! mas **noton.o.c.seems December 14. 1984

(.....

MEMORANDUM FOR: Harold R. Denton, Director .

Office of Nuclear Reactor Regulation Hugh L. Thoseson Jr.. Director Division of Human Factors Safety. NRR40 %pM THRU:

p FROM: William T. Russell. Deputy Director Division of Human Factors Safety. NRR

SUBJECT:

RESULTS OF JOINT NRR/01 INVESTIGATION AND EVALUATION OF RAYMOND R. 800HER

Reference:

1. Memorandum from S. J. Chilk (SECY) to 8. 8. Hayes (01) and W. J. Dircks (EDO) dated April 2. 1984.

Subject:

Staff Requirements-Discussion of Pending Investigation-TMI ..

2. Memorandum from H. R. Denton (NRR) to 8. B. Hayes (01) dated May 3. 1984.

Subject:

NRR Review of 01 Investigation Materials Concerning Hartman Allegations of Falsification of Leak Rate Data at TMI. Unit 2 The purpose of this memorandum is to document the results of the joint OI/NRR investigation and evaluation of Mr. Raymond R. Booher currently a Senior Reactor Operator (SRO) at Waterford Generating Station. Unit 3 and to provide a reconnendation regarding whether his current SR0 license should be revokeds modified, or suspended under 10 CFR 55.40 due to his involvement in praecci-dent leak rate testing irregularities at THI-2.

.' Background As a result of a Cosnission meeting on March 23. 1984 NRR was directed by Reference 1 to review 0! investigative materials concerning falsification of reactor coolant system (RCS) leak rate tests at THI-2 and refer back to 01 those matters which required further investigation. The results of NRR's review was provided in Reference 2. The review determined that follow-up investigation by 01 and further evaluation by NRR was needed in the case of NOTE: This memorandum and Enclosure 1 discusses information which is the sus' Ject of an ongoing O! investigation. This memorandum and Enclosure 3 discusses information that is maintained in the NRC's Privacy Act System 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. '

e r -, e,- s irm o - w,, -

g _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

r Harold R. Denton ,

seven licensed operators. Of the seven individuals identified in Reference 2, four are currently licensed at THI-2, two are licensed at Waterford 3 and one is licensed at San Onofre 2 and 3. At a follow-up Connission meeting on May 23, 1984, NRR proposed joint 01/NRR investigations and evaluations of these individuals. Subsequently, NRR issued letters to the seven individuals under 10 CFR 50.10(b) requesting additional information regarding current performance. Based upon investigation into the individuals' past involvement

, in improper activities at TMI-2 and an evaluation of the individuals'

{ subsequent performance NRR would recomend what action, if any, should be l taken against the identified operators.

) Past Involvement in THI-2 Leak Rate Testing Irregularities ,

On the afternoon of November 15, 1984, a joint DI/NRR interview of Mr. Raymond R. Booher was held in New Orleans, Louisiana. The interview was conducted under oath and in the presence of Mr. Booher's personal attorneys.

The purpose of the interview was to determine Mr. Bocher's role in improper activities associated with RCS leak rate surveillance testing at THI-2 prior to the accident on March 28, 1979. At that time, Mr. Booher was a licensed

-l Reactor Operator (RO) and served as a Control Room Operator (CRO) on shift "E." A detailed evaluation of Mr. Bocher's interview is included as Enclosure 1 to this memorandum.

While many of Mr. Booher's responses to questions associated with leak rate surveillance test problems at THI-2 are consistent with statements made to the NRC by other licensed operators, the majority of his responses regarding his personal involvement in or knowledge of leak rate test manipulation do not appear credible. During the interview Mr. Booher relayed tie following .

information.

l 1. Leak rate tests were routinely run at least once per shift. At times the tests had to be run several times before a satisfactory result was obtained (i.e., unidentified leakage within the Technical Specification limit of 1 gpm).

2. Only satisfactory leak rate test results were logged in the CR0 Log.

Test results which exceeded the Technical Specification limit were not logged. NOTE: These actions were centrary to TMI Administrative Proce-dure 1012. " Shift Relief and Log Entries," which required the start and stop times of all surveillance tests to be logged in the CR0 Log.

3. Only satisfactory leak rates were retained. All bad leak rate tests (i.e., unidentified leakage greater than the Technical Specification limit of 1 gpm). NOTE: These actions were contrary to TMI-2 Technical Specification 6.10. " Record Retention," which required that records of surveillance activities required by the Technical Specifications be retained for a period of at least 5 years.

i i

Harold R. Denton t .

9

4. Mr. Booher's first line supervision (Shift Foreman and Shift Supervisor) were knowkdgeable of the difficulties operators were experiehcing in obtaining satisfactory test results. These same individuals directed the throwing away of bad leak rate test results.

5. Contrary to the comitment contained in the narrative of LER 78-62/1T, Booher's shift was not instructed in the requirements ef applicable sections of the Technical Specifications or in the requirement to -

imediately invoke the Technical Specification Action Statement when the associated Limiting Conditions for Operation was exceeded. Booher stated that they did not abide by the shutdown requirements of tl.e Technical Specification because "that was more or less in the hands of management." NOTE: These actions are contrary to THI-2 Technical -

Specification TT 6.2, " Reactor Coolant System Operational Leakage Limiting Condition for Operation." and are contrary to the licensee's stated corrective action in LER 78-62/1T of November 1, 1978.

6. Mr. Booher stated that he was unaware that hydrogen additions to the j make-up tank could affect make-up tank level indication and, thus, favorably influence leak rate test results. NOTE: Mr. Booher's state-ment is in conflict with statements made by t1ie Two other CR0s on Mr. Booher's shift. Mr. Hartman and Mr. Blessing both admitted that they added hydrogen to the make-up tank to influence leak rate test results. They also indicated that it was comon knowledge among l

operators at THI-2 that hydrogen could alter leak rate test results. It was also Mr. Blessing's opinion that it was comon knowledge up to the ,

level of Shift Foreman and Shift Supervisor that operators were altering l 1eak rate tests using hydrogen.

7. Mr. Bocher stated that he never added water to the make-up tank for the purpose of altering leak rate test results. NOTE: Mr. Booher's state- ,

ment is in conflict with both the technical analysis and statements made  !

by Mr. Hartman. The technical analysis shows that during every leak rate test in which Mr. Booher took part from Decen6er 26,1978 through the date of the accident (8 tests), all include water additions to the make-up tank that were not accounted for in the leak rate test calcula-tion. Mr. Hartman has stated under oath that he personally witnessed Mr. Booher add water to the make-up tank in order to manipulate leak rate tests. The methods described by Mr. Hartman for adding water are the same methods which appear in the technical analysis.

In sumary, the weight of evidence, including technical analysis and state-ments by other operators on Mr. Booher's shift, strongly suggest that Mr. Bocher was not truthful in answering questions regarding his participation in or knowledge of leak rate test manipulation at TMI-2 during j the period September 30, 1978 to March 28, 1979.

i

j .

Narold R. Denton  !

Past Involvement in Breach of Security at TMI-2 ,

l On the afternoon of Noved er 15, 1984, a joint OI/NRR interview of.Mr. Bocher was held in New Orleans, Louisiana. The interview was conducted under oath and in the presence of Mr. Bocher's personal attorneys. The purpose of the interview was to determine Mr. Booher's role in an incident involving a breach of physical security at TMI-2 on July 13, 1979. A detailed sumary of this interview is provided as Enclosure 2 to this memorandum.

! The incident in question occurred at Three Mile Island on the evenin of

! July 13, 1979. At 11:10 p.m. that evening a safety-related Nuclear iver

! Pump (NRP-1A) tripped for no apparent reason. It was not until March 1, 1980 that a Met-Ed employee contacted an NRC Inspector and related, in confidence, his concern about the rehiring of a former Med-Ed employee named James Neagle.

• i He had heard from another enployee named Ray Bocher, that Neagle had allepedlyusedaboattogainaccesstotheTMIsiteontheeveningofJuly 13, 979. At that. time, Neagle was not employed by Met-Ed. It was further alleged that Mr. Neagle reportedly tripped NRP-1A while he was on the island and that he may have been armed when ttis excursion took place. Region I  :

completed its investigation into this matter on May 13, 1980 (See Region I j Investigation Report 50-320/80-04).

On the evening of the pump trip, Mr. Booher was the CR0 on watch. According to Mr. Bocher, the cause of the trip was not explained (i.e., there were no mechanical or electrical problems with the pump). However, sometime later

(time unknown), Mr. Bocher was informed by Mr. Neagle during a bar room .

! conversation, that Neagle sneaked aboard the island and tripped the pump.

Upon learning this information Mr. Booher did not report the incident. It

, was not until almost seven months after the incident, when Mr. Booher informed another operator about the incident and that operator reported the incident to the NRC, that any investigation into Neagle's actions was comenced. Throughout the interview, Mr. Bocher admitted his lack of action (i.e., not reporting the incident to his superiors) was a serious mistake.

He indicted that he has gained a great deal of experience since he was at TMI-2. Mr. Bocher's statement, that he was wrong and that he would guarantee it would not happen again, appear to be straight forward and credible.

Current Performance On Noveder 16, 1964, NRR conducted an interview and oral examination of Mr. Bocher, currently a Senior Reactor 0>erator at Waterford 3, in order to determine Mr. Booher's understanding of tis responsibilities for the safe

operation of the plant and his commitment to those procedures and operating i principles necessary to carry out those responsibilities. Interviews were also conducted with Mr. Booher's supervisors on November 14 and 15,1984. A write-up of Mr. Bocher's current performance is included as Enclosure 3 to i this memorandum.

i

Harold R. Denton -

5- December 14, 1984 Mr. Bocher appeared-to be confident, dedicated operator. He was obviously quite familiar with the procedures and operating principles necessary to safely operate Waterford 3. Both by implication and his own express statements, he is thoroughly committed to the safe coeration of the plant, and he fully expect: his co-workers to be similarly committed. He indicated that he expects complete candor from himself and his co-workers in all matters relating to the operation of the plant, and would not tolerate a lesser standard from his subordinates.

Interviews with Mr. Bocher's supervisors In addition, records of management appraisals of Mr. Booher's performance were reviewed.

Conclusions l

During the period Mr. Booher was licensed as a Control Room Operator at THI-2

. prior to the accident, he admitted he was involved in some activities associ-ated with leak rate testing irregularities. However, he denies that he was involved in other actions including leak rate test manipulation or falsifica-i tion or knowledge that such activities were going on around him. The weight of evidence, including statements by other operators en his shift and the l technical analysis, strongly suggests that Mr. Bocher was not truthful in answering questions regarding his role in leak rate test manipulation.

While Mr. Bocher's involvement in not reporting the breach of security at THI-2 also casts doubt on his judgement, I believe he learned his lesson from this event. I believe he now understands that an act of sabotage can not be considered a harmless prank.

l

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+ - ' - - - - - - - ---

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l Harold R. Denton l e

, it s'ppears that Mr. Booher h'as gained a great deal of experience since his termination with GPU. I believe Mr. Booher does understand his duties and responsibilities for the safe operation of Waterford 3 and that he is committed to following the approved procedures and operating principles necessary to carry-out those responsibilities.

Only three of the seven operators licensed at TMI-2 prior to the accident who are undergoing a similar joint 01/NRR investigation have been interviewed.

! It is possible that during the remainder of these interviews additional

- evidence could be developed regarding Mr. Booher's preaccident activities at' THI-2 that were not considered in this report. . . ..

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Irecommendthatenforcementactionnot'betaEena'ga' inst l Mr. Bocher at this time. Rather. I recommend that he be placed in a

probationary status until the expiration date of his current SRO license 4

(March 1, 1986). The renewal of Mr. Booher's license at that time would be dependent upon a satisfactory evaluation by both the licensee and NRC of his l performance during the probationary period.

Id.T. ib ="# k-William T. Russell Deputy Director l Division of Human Factors Safety l ,

Office of Nuclear Reactor Regulation

)

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

ongoing 01 investigation. This enclosure may not be dissemirated i i

outside the NRC without coordination with NRR and the permission of )

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

Enclosure 1 -

PAST INVOLVEMENT IN TMI-2 LEAK RATE TESTING IRREGULARITIES

1. Background on November 15, 1964, a joint Office of Investigations (01)/ Office of Nuclear Reactor Regulation (NRR) interview of Raymond R. Booher was held in the.

Federal Building, New Orleans, Louisiana. The purpose of the interview was to determine Mr. 01 son's role in improper activities associated with Reactor Coolant System (RC) leak rate surveillance testing at Three Mile Island, Unit 2 (TMI-2) prior to the accident on March 28, 1979. Present during the.

interview representing the NRC were: Keith Christopher Director. Office of l' Investigations, Region I; William Russell, Deputy Director Division of Human Factors Safety; and Robert capra. Technical Assistant. Division of Systems Integration. Representing Mr. Bocher at the interview were his personal attorneys: Jane Penny of the law fira Killian & Gephart, Harrisburg, Pennsylvania and William Marcoux of the law firm LeBoeuf. Lan6, Leiby and MacRae, Washington, D.C. Mr. Bocher was placed under oath for the interview.

, A copy of the transcript associated with this interview is provided as Attachment 1.

, Mr. Booher is currently employed by Louisiana Power & Light Co. as a Senior i' Reactor Operator (SRO) at Waterford Generating Station Unit 3. Mr. Booher has been employed at Waterford 3 since 1981. Prior to his current esployment, Mr. Bocher was em -

Metropolitan Edison Company (ployedMr.

Met-Ed). byBocher General Public was Utilities originally (GPU) hired by and

. Met-Ed Program.in Mr.1971 after Bocher serving worked as an6Auxiliary years inOperator the U.S. AO) Navy ('s Nuclear Submarine for approximately i 6 years before transferring to THI-2 as a licensed operator. He received his

Reactor Operator's (RO) license in 1976 and maintained it until his termination at TMI in 1981.

The interview with Mr. Booher concentrated on the period September 30, 1976 through March 28.-1979. During this time period he served as a Control Room Operator at TMI-2. He was assigned to Shift "E." At that time Shift "E" consisted of the following licensed individuals:

SHIFT "E" Shift Supervisor: Bernard Smith Shift Fortman: Kenneth Hoyt CRO: Raynsond Bocher CRO: Harold Hartman CRO: John Blessing

..----.,v,- - - - - -, , ,. - - - - - - -

t Mr. Bocher and Mr. Blessing were interviewed previously on this ilubject on April 10, 1960 during an NRC investigation into the "Hartman Allegation."

Copies of these reports of interview are included as Attachments 2.and 3, respectively. Mr. Hartman has been interviewed on this subject numerous times. A copy of his last interview with 01, dated July 26, 1983, is included as Attachment 4.

A sumary of the technical analysis of the leak rate tests involving Mr. Booher is provided in.Section II of this enclosure. A sumary of the interview with Mr. Booher is provided asSection III of this enclosure. The sumary of interview in Section III includes citations to the page numbers of transcript in which the sumarized information was discussed. Overall conglusions regarcing Mr. Booher's involvement in improper activities associated with THI-2 leak rate surveillance testing is contained in Section IV of this enclosure.

II. Sumary of the Technical Analysis A technical analysis of the THI-2 leak rate surveillance records was performed by Dr. Jin Chung of the Office of Inspection and Enforcement.

Region I. This analysis was originally done as technical suppert to the  ;

, Department of Justice in the criminal trial against Met-Ed. The results of Dr. Chung's analysis were used in questioning Mr. Bocher during the interview. While a more detailed sumary of the leak rate tests at THI-2 involving Mr. Bocher, along with the surveillance test sheets. CR0 Log extracts, and the make-up tank (MUT) strip charts for the questionable tests, '

are provided as Attachment 5 to this enclosure, a brief sumary of the results of the technical analysis will help the reader understand the basis .

for the questions posed to Mr. Booher during the interview.

A review of the test records show that of the 156 leak rate surveillance tests retained by the licensee during the period under investigation, Mr. Bocher was involved in 12 of the tests. During these 12 tests he was either the individual who signed the surveillance test record or he was the operator on watch who signed the CR0 Log for the period during which the test was conducted. Of these 12 tests, the analysis shows that 9 tests involved possible water or hydrogen additions to the MUT during the one hour time period in which the leak rate tests were conducted. The table below shows the breakdown of water / hydrogen additions.

Breakdown of LR Tests Involving - R. Booher Total Number of Tests on File 12 Tests Involving Hydrogen Additions 2*

Tests Involving Logged Water Additions 3 Tests Involving Unlogged Water Additions 5*

• 0n a test performed on 12/26/78 involved a hydrogen addition and an unrecorded water addition during i the same test.

The analysis shows that starting on December 26, 1978 through the date of the accident on March 28, 1979, all 8 tests involving Mr. Booher involved water additions that were not compensated for in computer calculation of. leak rate.

In one case (Decerter 26, 1964), both hydrogen and water were added during the leak rate test period.

The analysis relies to some degree of subjective judgment in some cases (i.e.. interpretation of the MUT level strip chart r&cerder trace). However, in the majority of tests involving Mr. Sooher, there is a high confidence level that these water and/or hydrogen additions were made during the same '

period the leak rate tests were being conducted. Three of the water additions involved the addition of large amounts of water (117 gallons to 300 gallons) and were logged into the CR0 Log as being added during the test, but none were taken into E count by the operator performing the laak rate test. In each case the satisfactory completion of the test was also logged into the CR0 Log. Mr. Bocher was the panel operator during these three tests and signed the log at the end of his watch, indicating he was responsible for these entries.

On one occasion a large amount of water (150 gallons) was added to the MUT and neither logged into the CR0 Log or compensated for in the leak rate test.

On four occasions, it appears that water was jogged into the make-up tank over longer intervals. The jogged additions may have been an attempt to hide the fact water was being added during the test. Two of these jogged additions involved Mr. Bocher and Mr. Hartman and two involved Mr. Bocher and Mr. Blessing.

NOTE: During Mr. Hartman's July 26, 1983 interview with DI, -

Hartman stated that he had personally witnessed operators use three methods to manipulate leak rate

. test result:

1. water addition in small undetectable amounts over the period of the test;

2. adding hydrogen to the MUT during the test; and

3. rerunning the computer leak rate until satisfactory results were obtained.

During this same interview, Mr. Hartman stated that he had witnessed Mr. Bocher add water to the make-up tank in order to manipulate leak rate test result.

In sumary, the technical analysis confirms what Mr. Hartman told OI on July 26, 1983. All eight tests (100%) involving Mr. Booher from December 26, 1978 on, involved actions that were not in accordance with approved procedures.

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-4 III. Interview Sumary  ;

After being placed under oath, Mr. Booher was asked to describe his eigloyment history prior to joining Louisiana Power & Light Co. Mr. Bocher

, stated that he had served six years in the U.S. Navy prior to joining Met-Ed in 1971. Mr. Bocher spent approximately 6 years as an Auxiliary Operator (AO) at TMI-1 prior to moving to TMI-2 as a licensed R0. See page 4. During the majority of the period under investigation, Mr. Bocher stated he was assigned to Shift "E" consisting of the following licensed individuals:

SHIFT "E" Shift Supervisor: Bernie Smith Shift Foreman: Ken Hoyt

_ CRO: Ray Booher CR0: Harold Hartman CRO: John Blessing See pages 5 and 6.

Mr. Booher was provided a copy of THI-2 Surveillance Procedure 2301-3D1,

" Reactor Coolant System Inventory" and a copy of THI-2 Technical Specification (TS) 3.4.6.2, " Reactor Coolant System Operational Leakage Limiting Condition for Operation." See page 6. After reviewing the documer.ts, Mr. Booher stated that he had performed leak rate tests at TMI-2.

, The TS required that a leak rate-test be performed every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />; however, they normally ran at least one every shift. See pages 7 and 36. Some shifts had to run more that one because the leak rate results did not meet the -

tolerance of the Limiting Condition for Operation (i.e., unidentified leakage in excess of the TS limits of I gpm). When bad results were received on a

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leak rate test, Booher. stated that they initially took them to the Shift Foreman. The bad leak rate tests would typically be thrown away based upon verbal instructions from either the Shift Foreman or the Shift Supervisor.

See pages 11 and 12.

When asked of the reason they were thrown away was so the NRC would not see them. Bocher stated it was never said to him that way. It was "just throw it away and perform another one."

When asked if it was implied that that was the reason to throw it away?

Bocher stated:

"Not to me, it w.:sn't. That wasn't implied until the grand jury. And then I remember seeing a letter evidently, the superintendent of operations wrote a letter saying, ' Dispose cf them more correctly.'"

See page 13.

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e Later in the interview, Mr. Bocher was asked if he could explain this document a little bit more. Bocher said:

"I don't remember at the site. But I remember of reading it in the grand jury, the fact that something was written to the effect to dispose of papers more accordingly into the trash cans instead of letting material lie around, to throw it away." See pages 35 and 36.

Mr. Booher stated that once they got a bad leak rate test result, they would continue to run the test until they received a good one. His rationale for accepting the good ones and rejecting the bad enes was that the leak rate tests not only came out positive, but came out negative as well, which was inpossible. Thus, he said with the accuracy of the instrumentation, you could either believe what you got or not. The ones that were within limits would be kept; the ones that were not would be thrown out. See pages 13 and 14.

When asked if he knew what to believe in the way of leak rates, Booher stated:

"I believe we had leakage, from experience, moreso from experience than from what the computer printout. Plus or minus or within spec. Because I could remember sending people out, like I used to in Unit 1, to take drainages from fan coolers or to look for leaks. We had leaks, sure." See page 14.

When Mr. Bocher was asked if he recalled ever entering the action statement on any of the leak rate tests that were outside the limits of the Technical

. Specifications, he responded that they did and they didn't. He said he could recall telling the Shift Foreman that the test results did not meet the Limiting Condition for Operation (LCO) and that they were in the action statement. However, he further stated"

...we really didn't really abide by the shutting down requirement though because that was more or less in the hands of management. Today, I would insist upon abiding by the action statement as it strictly said. Back then, we didn't."

See page 15.

Booher was then asked if he felt that he could rely on the RCS leak rate test calculation to tell him what kind of leakage they had. He said, " Hot an accurate one but we could use it for a trend." He was asked if he ever brought this to the attention of his supervisory personnel. Booher stated that they were the ones who made him aware of the instrument inaccuracies.

See pages 15 to 17.

+

6-Mr. Bocher was asked why he could now rememh r throwing away bad leak rate tests, yet, when he was interviewed in 1980, he could not recall what was  !

done with bad leak rate testa 7 Booher said that he had come into -the control room one morning and was told by Joe Chwastyk (a former Shift Supervisor) that the NRC wanted to talk to him about leak rates. Booher said: l "I went down there and I walked into this room and I see all these people, you know, and they all had note pads and were writing up a storm and I got somewhat nervous, to tell you the truth." See pages 18 and 19.

Mr. Bocher was then asked about how he interpreted the requirements of Technical Specification 3.4.6.2.

- NOTE: Part b of the Action Statement reads as follows: "With-any Reactor Coolant System leakage greater than any one of the above limits, excluding PRESSURE BOUNDARY LEAKAGE reduce the leakage rate within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least NOT STANDBY within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUTDOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />."

Mr. Booher stated that the operating philosophy was that regardless of how many bad leak rate tests were received during the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> period, as long as they received a valid one within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, they considered that they had met the Technical Specification requirements. See pages 20 and 21.

Mr. Bocher was then asked if he recalled an incident involving leak rate -

tests that occurred on October 18, 1978. Booher recalled that he remembered the incident from being questioned about it during the grand jury l . investigation; however, he did not recall the incident when he was at TMI.

NOTE: The incident referred to occurred on October 18, 1978.

During s routine inspection of THI-2 operations, an NRC inspector discovered that TH1-2 had been operating for a period of two or three days with unidentified leakage exceeding the Technical Specification limit. The incident resulted in the submittal of Licensee Event Report (LER) 76-62/1T dated November 1, 1978. The narrative of the LER states that "This event was caused by misinterpretation of the requirements of the technical specifications. The appropriate personnel will be instructed on the requirements of applicable sections of the T.S. and the requirement to innediately invoke applicable action statements when the provisions of the LCOs are not met."

1 l

. . l Mr. Bocher was shown a copy of the LER along with a routing sheet with the typewritten names and handwritten initials of control room personnel.

Mr. Bocher confirmed that the routing sheet was the normal method by which operators were kept informed of events such as this. He could not confirm if t the initials beside his name were his, which would indicate that he had seen the LER at one time. He stated they could be his; however, that was not his usual method of initialing. See pages 24 and 25.

Mr. Booher stated since he did not remember the incident, he did not believe that he was instructed, as the LER states, in the prcper interpretation,of the TS. He stated frem the date of the incident up to the date of the accident, his ir.terpretation of the TS did not change. As long as he received a valid leak rate test within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, he would not take the action required by the Action Statement. See pages 23 and 24.

When que:tioned about the mechanics of performing a leak rate test, Mr. Booher stated that there were normally 3 CR0s on watch. One was the panel operator for the primary plant, one took care of the secondary plant and one was assigned duties such as hanging dr.cger tags and surveillance tests. He stated that the operator assigned these duties (i.e., the 4

administrative duties) was the individua who normally performed the leak rate tests. He could not recall whether the primary or secondary panel operator maintained the CR0 Log. See pages 26 and 27. According to Bocher, the operator doing the leak rate test would try and keep the other operators informed that a leak rate test was in progress and not to change power, acd water, etc. See pages 27 and 26. Booher recalled; however, that they were not as good at comunications between operators as they should have been.

See page 26. ~

Booher said they logged only good leak rate tests in the CR0 Log. He could

. not recall ever logging the start times of any leak rate tests Lgood or bad).

Mr. Booher was provided with a copy of TMI Administrative Procedure 1012

" Shift Relief and Long Entries." Mr. Booher confirmed that the procedure required the start ard stop times of all surveillance tests be logged.

Mr. Booher said that it was out of ignorance of this requirement that operator did not log the start time of leak rate tests. He did not believe that they were intentionally kept from being logged in an attempt to deceive somecre into not realizing how many leak rate tests were being performed.

See pages 29 to 33.

Mr. Booher stated that he was not aware of any other surveillance test where bad results were thrown away. He stated leak rate tests were thrown away because they were so numerous. See page 34. Booher stated that his Shift Foreman and his Shift Supervisor M re aware that leak rate tests were being thrown away. He was never instructed to perform the leak rate test i differently cr not to throw away bad leak rate tests. See pages 34 and 35.

Hr. Bocher indicated that they would run at least one or two leak rate tests per shift. However, it was more difficult to get good leak rate test results as the date of the accident approached. See page 37.

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When questioned about the comnuter program for calculating leak Yate results, Booher stated that he was ccmfortable that he knew what was happening with leakage in the RCS. He did not have a problem with the computer program.

Booher stated that he did not attribute all of the problems with le~ak rate

. tests as being caused by instrument inaccuracies however. He attributed some of the problem with the leaking PORV or code safety valves. See pages 37 and 38.

The interview then concentrated on hydrogen additions. Mr. Booher stated that hydrogen was added from the control room when ever pressure in the MUT was low in the operating band or when it was necessary in order to maintain RCS chemistry within specifications. See pages 40 and 41. Although Booher considered the addition of hydrogen a 'iicliemical addition," he did not consider it the type of " chemical addition" that was precluded by the surveillance procedure for performing leak rate tests. See pages 42 and 43.-

Mr. Bocher was reminded of the allegstions made by Harold Hartman that hydrogen additions were used to manipulate leak rate test results and that Hartman had said, on more than one occasion, that he had observed Mr. Booher add hydrogen to alter leak rate tests. Mr. Booher was also informed that t

Mr. Blessing also admitted that hydrogen was used by operators to manipulate l leak rate tests. Thus, two out of the three CRO's on Mr. Booher's shift

' confirmed that this action was done. Mr. Bocher was asked to what e.xtent he had been involved in this type of activity. He responded:

"Like I testified in the grand jury, I personally don't ever remember of adding hydrogen to affect the make up tank level.

I remember of hearing discussions. I don't remember when the .

discussions were. But I thought it was kind of ridiculous, to tell you the truth, to have some kind of a gas make a level change. I still believe that, to tell you the truth. I don't t understand how adding hydrogen to a tank would make the level change." See 45 and 46.

Mr. Bocher was questioned further about when the discussions he referred to.

above took place. Mr. Bocher could not recall. He did not know if it was during his April 1980 interview or at some time prior to the accident. M page 47.

Mr. Booher stated that he did not understand, even today, how MUT level could l be altered by the addition of hydrogen. He was informed that it did not I matter if an operator understood g adding hydrogen produced a change in MUT level, as lon relationship.g as the operators Many operator knew did notthat there was understand a cause why and effect it happened, but nonetheless used the phenomenon to get good leak rate test result. See pages 47 and 48.

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Mr. Bacher stated that he did not recall Mr. Blessing telling him that he ever added hydrogen to effect test results. He said he had a good.

relationship with Hartman and, thus, did not know why Hartman would state that he had personally witnessed Bocher add hydrogen to effect leak rate tests. Booher could also not recall if Hartman and he ever entered into a discussion about whether hydrogen could change MUT level. Booher was not aware of any operator making hydrogen additions to alter leak rate test results. See pages 48 to 52.

NOTE: In his April 1960 interview Hr. Blessing stated, C it was no secret that hydrogen was being added to the ,

makeup tank during the running of the reactor coolant surveillance test and it was totally comon practice. In this

_ same interview, however, Mr. Blessing stated that while he knew from personal knowledge that Hartman had added hydrogen to the makeup tank to get good leak rates, he could not say for a fact that Ray Bocher had added hydrogen or water or in

any other way falsified the leak rate.

When asked if he was ever directed to make hydrogen additions for the purpose of altering leak rate tests, Cooher responded, no. He stated that he would definitely remember being told that. See pages 53 and 54.

Mr. Boeher admitted that there was pressure to get good leak rates; however, he did not recall any particular supervisor applying pressure. There was pressure, he said, because good leak rate test results were hard to get. See page 54. While Booher admitted that there was pressure, he did not feel his.

job was in jeopardy if he was not able to obtain a satisfactory leak rate test by the end of his eight hour shift. See page 55.

Bocher stated that he could not recall any discussions by management personnel or supervisors about problems with leak rate tests. He stated that I discussions of that nature would normally be held in the Shift Supervisor's Office and not in the Control Room. See page 56. He did not recall having any discussions about leak rate test with anyone except the other operators on his shift and with other operators during watch relief. See pages 56 and 57.

Mr. Booher believes that had Hartman added hydrogen to manipulate leak rate tests that Hartman would have told him; however, he does not recall any such discussions. Booher also said it would be possible for one operator to add hydrogen during a leak rate test without the other operators being aware of it. See pages 59 and 60.

In sumarizing Mr. Bocher's testimony regarding hydrogen:

1. He was not aware, at the time, that either Hartman or Blessing or any other operators were adding hydrogen to manipulate leak rate tests.

2. He has no reason te believe that tests were altered by the additicn cf l

hydrogen.

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3. Hedidnoteverrecalldiscussingwithotheroperatorsthebossibility of altering leak rate tests by the addition of hydro

4. There was no individual (management and supervisory) who gen to thethat indicatea MUT.

they should add hydrogen to alter leak rate tests. g pages 61 and 62.

The next portion of the interview concentrated on the use of water additions to manipulate leak rate tests. Mr. Booher stated that water additions were required to be logged in the CR0 Log. He stated that it was possible to add water during the performance of leak rate test and properly account for it by

- entering the proper amount into the computer at the end of the leak rate.

test. He stated that if he added water, that is what he would do. It is also possible, according to Booher, that water was added during.a test and not properly accounted for in the test. But, he did not think that that ever happened. See pages 63 to 65.

Booher stated that he did not remember making a water addition during the performance of a leak rate test for the purpose of intentionally altering a leak rate test. He was then asked if "by don't remember," he meant he could have done it, but did not remember or did he mean that he didn't do it.

Bocher responded: "Of course, anything is possible but I don't remember adding water to influence a leak rate." See page 66.

An excerpt of Mr. Hartman's July 26, 1983 interview with DI was read to Mr. Booher.

Question to Mr. Hartman: "What specific operators did you witness add water to the make up tank in order to manipulate leak -

rate tests?"

Answer by Mr. Hartman: " Ray Booher, because he was on my shift."

l Mr. Booher responded to Mr. Hartman's allegations by stating: 'If I remembered, I would tell you but I don't remember. b page 73.

Mr. Booher was provided with a copy of the technical analysis of his leak rate tests. After a short break to allow him to review the document, a detailed discussion of several of the leak rate test results took place. In almost all cases reviewed Mr. Booher disagreed that the analysis showed water had been added during the tests. However, no credible explanations were offered to explain the phenomena that are present on the MUT level strip charts. It was pointed out to Mr. Bocher, in a few cases the technical l analysis is subject to judgment; however, in the majority of cases the water I

additions were quite apparent. In three cases water was added to the MUT and logged in the CR0 Log by Mr. Booher, yet these water additions were not included in the computation of leak rate results. See pages 71 to 110.

l Mr. Bocher was informed that in Mr. Blessing's 1980 interview, Blessing l stated that it was comon practice by a large portion of the Control Rocm Operators to add hydrogen to the make-up tank while rerunning leak rate

P surveillance tests in order to assist in getting a good leak rate test result. Blessing emphasized that it was no secret that hydrogen was being added to the make-up tank during tests and that it was his opintori that Shift Supervisors and Shift Foreman were well aware of this practice. Booher was then asked, with statements like Mr. Blessing's, how could he deny that he had no knowledge that this practice was going on. Booher's response (although referring to Harold Hartman) was

• Evidently, Harold didn't like me a hell of a lot either because I read a statement in the grand jury where Ray wasn't a very good operator." See pages 115 to 117.

NOTE: While referred to at this point in the interview, but not read a Mr. Booher, a statement was made in a recent interview with another former TMI-2 CR0 M. V. Cooper on September 28, 1984. During Mr. Cooper's interview, he stated that he strongly suspected Mr. Hartman and Mr. Booher of manipulating leak rate test results during the period under investigation. A copy this portion of Mr. Cooper's interview is included as Attachment 6 to this enclosure.

Mr. booher again stated for the record that he had no knowledge of anyone manipulating leak rate tests at TMI-2. This included Messrs. Hartman, Blessing, Cooper, Congdon and Coleman. See page 121.

At the close of the interview, Mr. Bocher was informed that based upon his '

testimony and the testimony of others, it was difficult to reach a conclusion that he was not involved in leak rate manipulation or that he had no kncwledge of what was going on around him. See page 122.

IV. Conclusions While many of Mr. Booher's responses to questions associated with leak rate surveillance test problems at TMI-2 were consistent with statements made to the NRC by other licensed operators, the majority of his responses regarding his personal involvement in or knowledge of leak rate test manipulation do not appear credible. During the interview Mr. Booher relayed the following information.

1. Leak rate tests were routinely run at least once per shift. At times the tests had to be run several times before a satisfactory result was obtained (i.e., unidentified leakage within the Technical Specification limit of 1 gpm).

2. Only satisfactory leak rate test results were logged in the CR0 Log.

Test results which exceeded the Technical Specification limit were not legged. Note: These actions were contrary to TMI Administrative

e Procedure 1012. " Shift Relief and Log Entries," which required the start and stop times of all surveillance tests be logged in the CR0 Log.

3. Only satisfactory leak rate tests were retained. All bad leak rate tests (i.e., unidentified leakage greater than the Technical Specification limit of 1 gpm). . Note: These actions were contrary to THI-2 Technical Specification 6. W " Record Retention," which required that records of surveillance activities required by the Technical Specifications be retained for a period of at least 5 years.

4. Mr. Booher's first line supervision (Shift Foreman and Shi.ft Supervisor) were knowledgeable of the difficulties operators were experiencing in obtaining satisfactory test results. These same individuals directed

- the throwing away of bad leak rate test results.

5. Contrary to the cournitment contained in the narrative of LER 78-62/1T, Booher's shift was not instructed in the requirements of applicable sections of the Technical Specifications or in the requirement to innediately invoke the Technical Specification Action Statement when the associated Limiting Condition for Operation was exceeded. Booher stated that they did not abide by the shutdown requirements cf the Technical Specitication because "that was more or less in the hands of w.anagement." Note: These actions are contrary to TMI-2 Technical Specification TU6.2, " Reactor Coolant System Operational Leakage Limiting Condition for Operation," and are contrary to the licensee's stated corrective action in LER 78-62/1T of November 1, 1978.

6. Mr. Bocher stated that he was unaware that hydrogen additions to the make-up tank could affect make-up tank level indication and, thus, favorably influence leak rate test results. Note: Mr. Booher's statement is in conflict with statements made by the two other CR0s on Mr. Bocher's shift. Mr. Hartman and Mr. Blessing both admitted that they added hydrogen to the make-up tank to influence leak rate test

! results. They also indicated that it was common knowledge among operators at TMI-2 that hydrogen could alter leek rate test results. It was also Mr. Blessing's opinion that it was cournon knowledge up to the i level of Shift Foreman and Shift Supervisor that operators were altering l

1eak rate tests using hydrogen.

7. Mr. Bocher stated that he never added water to the make-up tank for the purpose of altering leak rate test results. Note: Mr. Booher's statement is in conflict with both the tect.aical analysis and statements made by Mr. Hartman. The technical analysis shows that during every i leak rate test in which Mr. Booher took part from December 26, 1978 through the date of the accident (8 tests), included water additions to the make-up tank that were not accounted for in the leak rate test calculation. Mr. Hartman has stated under oath that he personally witnessed Mr. Bocher add water to the make-up tank in order to l

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manipulate leak rate tests.- The authods described by Mr. Har'tman for I adding water are the same methods which appear in the technical i analysis. -

In summary, the weight of evidence, including technical analysis and statements by other operators on Mr. Booher's shift, strongly suggests that Mr. Booher was not truthful in answer.ing questions regarding his participation in or knowledge of leak rate test manipulation at THI-2 during the period September 30, 1978 to March 28, 1979.

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ENCLOSURE 2 PAST INVOLVEMENT IN BREACH OF SECURITY AT TMI-2 e

I. Background On November 15, 1964, a Reactor Regulation (NRR) joint Office interview of Investigation of Raymond R. Booher(01)/

was Office held inof Nuclear the Federal Building, New Orleans, Louisiana. The purpose of the interview was to determine Mr. Booher's role in an incident involving a breach of physical security at THI-2 on July 13, 1979. Present during the interview represent-ing the NRC were: Keith Christopher, Director, Office of Investigation, Region I; William Russell, Deputy Director, Division of Human Factors Safety; and Robert Capra, Technical Assistant, Division of Systems Integration.

Representing Mr. Booher at the interview were his personal attorneys; William Marcoux of the law firm LeBoeuf, Lamb Leiby and MacRae, Washington, D.C. and l Jane Penny of the law firm K1111am & Gephart, Harrisburg, Pennsylvania. Mr.

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Booher was previously placed under oath during his leak rate interview I earlier in the afternoon. A copy of the transcript is included as an attachment to this enclosure.

On March 1, 1980, a Met-Ed employee contacted an NRC Inspector and related, in confidence, his con ern about rehiring of a former Met-Ed employee named James Neagle. He had heard from another employee named Ray Booher, that Neagle had allegedly used a boat to gain access to the TMI site on the evening of July 13, 1979. At that time, Neagle was not employed by Met-Ed.

It was further alleged that while on the Island, Mr. Neagle reportedly tripped a Nuclear River Pump (NRP-1A) and that he may have been armed when this excursion took place. An investigation was begun on March 5, 1980 by Region I.

On May 13, 1980, Region I completed its investigation (See RI Investigation Report 50-320/80-04). Region I concluded that NRP-1A dTirtrip for "no

, apparent reason" at 11:10 p.m., July 13, 1979. Interviews with three individuals, including Mr. Booher, who was the CR0 on watch at the time of the incident, confirmed that Mr. Neagle revealed to them that he had entered the island illegally that night and tripped the pump.

II. Summary of Interview Mr. Booher was questioned regarding the incident described above. Mr. Booher indicated that he did recall the incident and confirmed that he was on watch in the Control Room on the night of the incident. Mr. Booher stated that following receipt of an alarm, he dispatched an operator to the pump house to determine the cause. The operator reported back that the cause of the could not be determined (i.e., the pump tripped for no apparent reason) pumpSee .

l pages 3 to 4 Mr. Bocher stated it was sometime after that, a month, a year, one of his ex-operators said he had a problem with security and he went in and tripped I

the pump. Mr. Booher stated that this was told to him by Mr. Neagle during a

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2- i i

l bar room conversation. When asked how the subject came up, Mr.,Booher .

responded that Mr. Heagle came up to him at the bar and asked if anything i unusual had happened at the plant. Bocher thinks he then told Mr. Neagle that NRP-1A had tripped. Mr. Neagle then informed Mr. Booher that-he was the individual that caused the pump to trip. See page 4 Mr. Booher was informed that that seemed like an unusual thing to remember when asked such a general question, a month or a year later, as Mr. Bocher had indicated. Mr. Booher then stated that it was possible it could have been the next day or the same night of the incident. Mr. Bocher did not believe, however, that he received a phone call while he was still on watch.'

He said he would have remep6ered that. M pages 4 to 6 Mr. Bocher confirmed that NRP-1A was classified as safety related. Mr.

Booher was asked what action he took after being informed by Mr. Neagle that he had sneaked onto the island and tripped a required piece of safety-related equipment. Mr. Bocher stated that he did not recall telling any one, and that later he was suspended by the Cog any for 10 days for his actions. See pages 7 and 8 Mr. Booher stated that even though it was a bar room conversation, he should have rr. ported the incident. He said he should have reported it without any hesitation at all. Even if the individual had not have tripped off the pump, the fact tha't he was on the site without an escort should have been reported.

See page 9 When asked what he would do in a similar situation today at Waterford 3. Mr.

Booher stated that he had gained an awful lot of experience since those days at THI, he would first notify security, second he would check the " potential-reportable event procedure" for reportability requirements, and finally he would notify his issnediate supervisors. g pages 10 and 11.

l A suninary of Mr. Vastine's testimony (a Met-Ed egloyee at the time) was gone 1

over with Mr. Booher. Mr. Vastine's testimony indicated that Mr. Neagle had informed Vastine that Neagle called the Control Room and reported to the operator on n .ch that Neagle was the individual who had tripped the pump.

Mr. Booher reiterated that he would have remembered receiving such a call;

however, he states he did not receive a phone call. He maintained that he did not learn about the Neagle's~ involvement until the bar room discussion referred to above. See pages 14 and 15.

It was also pointed out tc Mr. Booher that based upon the testimony of Mr.

Adams and Mr. Chwastyk (Shirt Foreman and Shift Supervisor, respectively) it was Mr. Adams who first confronted Mr. Booher rather than Mr. Booher volun-toering the information to Mr. Adams. Mr. Booher stated, " Yeah, in this whole incident, I can see a definite fault in not reporting that conversa-tion." See page 16

Mr. Bocher was informed that with respect to the pump trip and that investi-gation the NRC is concerned how that might relate to his judgment and integrity. Clearly, the NRC has to rely upon the candor and forthrighness of licensed operators. Not only their accountability for their own actions, but )

also their willingness to discover problens and report those problems, to i ferret out issues. See pages 18 and 19 Mr. Booher was further informed that this situation that he became aware of was a breach in security, an act of sabotage from the standpoint of turning off a safety-related pump that was required for coc11ng at the time. See page 19 III. Conclusion Mr. Booher has readily admitted that the actions he took as a result of this incident were wrong. He has indicated that he has gained a lot of experience since he was at TMI. Mr. Booher appears to be sincere and straight forward when he stated that "I was wrong, but I can guarantee it won't happen today."

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NOTE: This enclosure discusses information that is maintained in the NRC's Privacy Act System of Records (NRC-16). This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO. Internal access and distribution should be on a "need to know" basis. ,

Enclosure 3 -

1. Background On November 16, 1984, an interview was conducted with Mr. Raymond Bocher, a Senior Reactor Operator at Waterford Generating Station, Unit 3 in order to determine Mr. Booher's understanding of his responsibilities for the safe operation of the plant and his comitment to those procedures and operating principles necessary to carry out those responsibilities. Participating in the interview from the NRC were William Russell, Deputy Director, Division of Human Factors Safety and Leonard Wiens, Senior Examiner, Operator Licensing Branch. Mr. W. C. Marcoux and Ms. Jane Penny, Attorneys representing Mr. Bocher, were also present at the interview. In addition to the interview with Mr. Booher, interviews were conducted with Mr. Booher's supervisors on Noven6er 14 and 15,1984.

Superviscrs interviewed include:

Name Position / Title 0.D. Hayes Operations Superintendent C. Toth Licensed Operator Training Superintendent J. Edwards Shift Supervisor j M. Bourgeois Shift Supervisor Section II provides a sumary of the interviews with Mr. Bocher and the -

supervisors identified above.Section III provides an overall conclusion regarding Mr. Booher's current performance.

II. Interview Sumary Mr. Booher appeared to be a confident, dedicated operator. He was obviously '

quite familiar with the procedures and operating principles necessary to safely operate Waterford 3. Both by implication and his own express statements, he is thoroughly comitted to the safe operation of the plant, and he fully expects his co-workers to be similarly comitted. He indicated 1 that he expects complete cander from himself and bis co-workers in all I matters relating to the operation of the plant, and would not tolerate a l 1 esser standard from his subordinates.

2-III. Conclusion e

, Enclosure 4

/p a*49'g UNITED STATES 8 e NUCLEAR REGULATORY COMMISSION i .l WASHINGTON, D. C. 20555 4 May 30,1985 4..,...,/

MEMORANDUM FOR: Harold R. Denton, Director Office of Nuclear Reactor Regulation ,

FRON: William T. Russell, Acting Director

. Division of Human Factors Safety, NRR

SUBJECT:

RESULTS OF JOINT 01/NRR INVESTIGATION AND EVALUATION OF JOSEPH R. CONGDON

Reference:

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

Subject:

Staff Requirements-Discussion of Pending Investigation-TMI

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2. Memorandum from H. R. Denton (NRR) to B. B. Hayes (01) dated May 3, 1984, Subject NRR Review of OI Investi-gation Materials Concerning Hartman Allegations of Falsification of Leak Rate Data at THI, Unit 2

3. Memorandum from W. T. Russell (DHFS) to H. R. Denton (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. Joseph R. Congdon, currently a Licensed Senior Reactor Operator (SRO) at Three Mile Island, Unit 2 assigned as Shift Foreman, and to provide a recomendation regarding whether his current SRO license should be revoked, modified, or suspended under 10 CFR 55.40 or other enforcement action taken under 10 CFR Part 55.50, due to his involvement in

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preaccident leak rate testing irregularities at THI-2.

Background

As a result of a Comission meeting on March 23, 1984, NRR was directed by Reference 1 to review 01 investigative materials concerning falsification of reactor coolant system (RCS) leak rate tests at THI-2 and refer back to 01 NOTE: This memorandum and Enclosure 1 discusses information which is the subject of an ongoing 01 investigation. This memorandum and Enclosure 2 discusses information that is maintained in the NRC's Privacy Act System of Records (NRC-16). This memorandum and enclosures may not be disseminated outside the NRC without ccordi-ration with NRR and the permissicn of the EDO cr the Directer, 01.

Internal access and distribution shculd be on a "need to knew" basis.

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l Harold R. Denton -2 May 30,1985 I l

l those' matters which required further investigation. The results of NRR's review was provided in Reference 2. The review determined that follow-up investigation by 01 and further evaluation by NRR was needed in the case of seven currently licensed operators. J. R. Congdon was one of these seven l individuals. At a follow-up Comission meeting on May 23, 1984 NRR pro-posed joint DI/NRR investigations and evaluations of these individuals.

l Subsequently NRR issued letters to these individuals under 10 CFR 65.10(b) l . requesting additional information regarding current performance. Based upon the joint investigation into the individuals' past involvement in improper i

activities at THI-2 and an w aluation of the individuals' subs %uent per- 1 formance, NRR would recomend what action, if any, should be taken against the identified operators. As a result of some of the early interviews with these individuals and further technical analysis Reference 3 recommended that three additional currently licensed operators also be interviewed. NRR issued similar letters to these individuals under 10 CFR 55.10(b). Of the ten individuals identified for investigation, seven are currently licensed at Three Mile Island, Unit 2, two are licensed at Waterford 3 and one is licensed at San Onofre 2 and 3.

Past Involvement in TMI-2 Leak Rate Testing Irregularities On January 29, 1985, a joint Office of Investigations (01)/ Office of Nuclear l Regulation (NRR) interview of Joseph R. Congdon was held in the law office of Killian & Gephart. Harrisburg, Pennsylvania. The interview was conducted in the presence of Mr. Congdon's personal attorneys. The purpose of the interview was to determine Mr. Congdon's role, if any, in improper activities associated with RCS leak rate surveillance testing at THI-2 prior to the accident on March 28, 1979. At the time, Mr. Congdon was a licensed Reactor Operator (RO) and served as a Control Room Operator (CRO) on Shift "C." A detailed evaluation of Mr. Congdon's interview is included as Enclosure 1 to this memorandum.

Throughout Mr. Congdon's interview he appeared to answer questions in an honest, straightforward manner. His testimony was consistent with the

. information provided by many of the other Control Room Operators at THI-2 who have been recently interviewed by 01/NRR. Mr. Congdon's statements were also consistent with the Department of Justice's Statement of Facts 37 and other evidence developed by 01 during its earlier TMI-2 Leak Rate Investigation. During the course of the interview, Mr. Congdon provided the following information: ,

1. Congdon's shift tried to run at least one leak rate test per watch. He stated they may have had to run two or three tests during a watch I because it was sometimes difficult to get stable plant conditions.

2. Mr. Congdon stated that wher leak rate test results were greater than the limit allowed by the Tet.hnical Specifications, they would initiate the follow-up actions required by the procedure, including running M Statement Of Facts Submitted By The Unitec States, United States v.

Metropolitan Edison Cercany (Criminal No. 83-00188), February Zei,1984.

\ _ . _ - ,

Harold R. Denton May 30,1985 backup tests and looking for the source of the leakage; however, he stated that they did not enter the Action Statement of the Technical Specifications.

l 3. Once an acceptable leak rate test result was obtained, the unsatis-factory test results would be thrown away by either the operator or the Shift Foreman. He believed that his Shift Supervisor and the Supervisor of Operations were both aware of this practice.

4. Mr. Congdon believed that there were times when they had received a leak rate test result that showed unidentified leakage was greater than the one gpm limit and they did not receive an acceptable. result within the following four hours. He stated that as they approached the date~of the accident, it became more difficult to get acceptable leak rate test results. .

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Wote: The Action Statement of Technical Specification 3.4.6.2 requires:

If Reactor Coolant System Unidentified Leakage is greater than one gpm, reduce the leakage rate within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least HOT STANDBY within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUTDOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.

! 5. Mr. Congdon agreed with the statements of his former shift-mate, i Mr. Cooper, that the operators had little faith in the RCS leak rate

test calculations that were performed to show compliance with the j -

Technical Specifications, and that test results were erratic even when tests were run back to back with the same stable plant conditions.

Mr. Congdon also stated that regardless of the results of the sur-veillance test, he believed that the operators knew whether they had leakage or not from observing many of the other parameters in the plant.

6. Mr. Congdon stated that they routinely logged the completion time and the results of the acceptable tests but did not log the unacceptable

, tests. He denied that they were not logging the start times of all tests in order to hide the fact they were running so many tests. He was never instructed by supervisory personnel not to log in the results of bad tests. Note: Administrative Procedure 1012 required that the test title, test number, and the start and completion times of all surveillance tests required by the Technical Specifications be logged in the CR0's Log.

7 .- Mr. Congdon stated that LER 78-62/1T did not have any impact on the way leak rate tests were conducted on his shift. Following issuance of the LER, Mr. Congdon did recall being told to ensure that bad leak rate test results were thrown away and not to leave them lying around the control room where the NRC could find them. Although he was not positive, he recalled that his Shift Supervisor, Brian Mehler was the individual who provided that instruction. He also believed that his Shift Foreman, Chuck Adams was present at the time that instruction was given. Note:

Mr. Congdon's recollection of this instruction is consistent with state-ments made by Mr. Cooper during his Ol/NRR interview on September 28, 1984. Note: LER 78-62/1T stated that leak rate surveillance test problems we're caused by a misinterpretation of the requirements of the Technical Specifications and that appropriate personnel would be

' Harold R. Denton May 30,1985

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, instructed on the requirements of the applicable sections of the Technical Specifications and the requirement to immediately invoke the applicable Action Statements when the provisions of the Limiting Conditions for Operation were not met. ,

8. Mr. Congdon stated that he did feel pressure to get a good leak rate.

He said that it would be brought to their attention at shift briefings that they needed to get a good leak rate test. He said that they were trying to comply With that direction and still get everything else done that they had to complete on the shift.

9. Mr. Congdon said that the operators did not like having to operate the plant with high identified leakage, since it led to many other operational problems while they were on watch. He stated, however, that they considered it a situation that they could live with in a safe manner. When Mr. Congdon was asked if the operators on his. shift believed that the plant should be shut down to correct the problem and l not wait for the planned outage, Mr. Congdon stated "we shared that ,

attitude to one degree or another." He also believed that this attitude was shared by his Shift Foreman and his Shift Supervisor.

10. Mr. Congdon stated that sometime around February 1979, he became aware of the fact that hydrogen additions to the make-up tank (MUT) could influence MUT level and hence leak rate test results. He described an

experiment that was run on his shift by the Shift Foreman to determine if the hydrogen additions could influence MUT level and hence test results.

11. Mr. Congdon stated that at the time, he did not consider hydrogen additions during leak rate tests to be a violation of the procedure.

! Yet, he admitted that he added hydrogen to the MUT during leak rate -

tests with the intent of influencing leak rate test results. He stated -

that adding hydrogen did not always produce the same effect. He believed that the other CR0s on his shift were aware that this was being l .

. done and that both his Shift Foreman and his Shift Supervisor were also aware that hydrogen was being added during tests for the purpose of manipulating test results. Although he could not provide any details, he did not think that hydrogen additions were limited to just their shift.

12. Mr. Congdon stated that to the best of his knowledge, he did not intentionally add water to the MUT for the purpose of influencing leak rate test results. If water additions did occur and were not included in the calculation, he felt it may have been caused by miscomunication between the operator performing the test and the operator on the panel.

Mr. Congdon stated that while he did not consider hydrogen additions to the MUT during leak rate tests a procedural violation at the time, he would have considered an intentional, unaccounted for water addition during the leak rate test a blatant violation of the procedure.

13. Hr. Congdon was not aware until after the accident that operators may have been adding water to the MUT in an attempt to influence leak rate tests. He did not recall any discussions with other operators that they were making water additions for that purpose.

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l May 30,1985

. Harold R. Denton 1

It is clear from his testimony, that

- while he was involved in activities that violated approved procedures and Technical Specifications, his actions were common practice among operators at TMI-2 and that his first line supervision and possibly middle level manage-ment were aware of these practices and openly sanctioned these activities.

Current Performance ~

1 Throughout the interview, Mr. Congdon appeared to be a very conscientious, dedicated operator. He seemed to be sincerely committed to operating.the plant safely and in accordance with all procedures and regulations. During the interview, he displayed a quiet, confident attitude, and always seemed to logically think through any situation in which he was placed. He demonstra-ted a thorough knowledge of plant procedures ~and Technical Specifications, and his answers reflected a significant amount of operational experience.

The overall impression was that of an experienced operator who used good operating practices on a daily basis.

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" Harold R. Denton Phy 30,1985

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. Conclusions ,

During the period Mr. Congdon was licensed as a Control Room Operator at THI-2 prier to the accident, 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 THI-2 Technical

! Specifications. These actions included attemsted manipulation of test results through the addition of hydrogen to tie make-up tank during periods when leak rate tests were being run. Mr. Congdon denied; however, that he ,

used other methods such as unaccounted for water additions to influence test results.

The results of the technical analysis shows that between September 30, 1978 and March 28, 1979, 20 of the 28 tests (715) involving Mr. Congdon involved evolutions that were contrary to the precautions and limitations of the Surveillance Procedure (2301-3D1) used to conduct leak rate tests. These evolutions included: unstable plant conditions; use of an unstable make-up tank level transmitter to provide input to the plant computer; feed and bleed operations; water additions that were not properly included in the test -

. calculation; and hydrogen additions to the make-up tank. Based upon the high numb'er of questionable or invalid tests, coupled with Mr. Congdon's testimony, it appears that tests were conducted so frequently that test

. results were accepted as valid as long as the result was less than the

. Technical Specification limit, regardless of the evolutions in progress during the test and that some of these evolutions were performed with the intent of manipulating or influencing the outcome of the test results.

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Harold R. Denton May 30,1985

.. [ Based upon the testimony of the majority of other CRO's interviewed to date, it is clear that management's standards for procedural compliance were lax and permissive. In my opinion, this was created through negligence on the part of management. Lack of operator respect for the leak rate test procedure coupled with management's failure to correct test

- procedure problems and to instill high standards for procedure compliance led-to conditions that motivated some operators to falsify leak rate tests.

Mr. Congdon is now willing to admit his involvement in activities that were wrong. He recognizes the seriousness of these activities and is willing to accept responsibility for.his actions. .

t i t is 'a

'pparent that he ha's learne'd from his past mistakes and has

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subsequently developed a much more thorough understanding of his duties and responsibilities as a licensed Senior Reactor Operator. I believe that Mr. Congdon does understand his duties and responsibilities for conducting safe operations at THI-2 and that he is committed to following the approved procedures and operating principles necessary to carry-out these responsibilities. .

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, ~ . 'I reconsnen[ thai '

Mr. Congdon be placed in a probationary status until the expiration date of his current SRO license (January 22,1986). The renewal of Mr. Congdon's license at that time would be dependent upon a satisfactory evaluation of his performance during the probationary period by both the licensee and NRC.

h .[ O William T. Lussell Acting Director Division of Human Factors Safety Office of Nuclear Reactor Regulation

Enclosures:

As stated cc: B. hayes K. Christopher

, . - - - - - - - ,n.

h0TE: This enclosure discusses information which is the subject of an

. ongoing 01 investigation. This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO or the Director. 01. Internal access and distribution should be on a "need to know" basis.

Enclosure I ,

PAST INVOLVEMENT IN THI-2 LEAX RATE TESTING IRREGULARITIES I. Background

]

on January 29, 1985, a joint Office of Investigations (OI)/ Office of Nuclear Reactor Regulation (NRR) interview of Joseph R. Congdon was held in the law office of Killian & Gephart, Harrisburg, Pennsylvania. The purpose of the interview was to determine Mr. Congdon's role, if any, in improper activities associated with Reactor Coolant System (RCS) leak rate surveillance testing at Three Mile Island, Unit 2 (TMI-2) prior to the accident on March 28, 1979.

_. Present during the interview representing the NRC were: R. Keith Christopher, Director Office of Investigations, Region I; William T. Russell, Deputy Director, Division of Human Factors Safety; and Robert Capra, Senior Program Manager, Staff of the Executive Director for Operations. Representing Mr. Congdon at the interview were his personal attorneys, Mr. Smith B.

Gephart of the law firm Killian & Gephart Harrisburg, Pennsylvania and Mr. Harry H. Voight of the law firm LeBoeuf. Lamb. Leiby and MacRae, Washington, D.C. Mr. Congdon's April 30, 1979 interview with the NRC is included as Attachment 1. A copy of the transcript associated with this interview is provided as Attachment 2 to this enclosure.

Mr. Congdon is currently employed by General Public Utilities Nuclear Corporation (GPUN) as a Shift Foreman at THI-2. Mr. Congdon holds a Senior Reactor Operator's (SRO) license for TMI-2. Prior to joining Metropolitan -

l Edison Company (Met-Ed) in January 1974, Mr. Congdon served as a Mechanical Operator in the U. S. Navy's nuclear submarine program. He was first hired by Met-Ed as an Auxiliary Operator (AO) at THI-1. He remained in that position for approximately three years after which he was placed in the cold licensing operator training group for Control Room Operators at TMI-2.

He received his Reactor Operator's (RO) license in October 1977 and served as a CR0 at TMI-2 until approximately one year after the accident. Mr. Congdon next served in the Training Department for approximately three years during which time he receiving his Sk0 license iri January 1982. Following his ,

assignment to the Training Department, Mr. Congdon returned to TMI-2 as a Shift Foreman, the position that he currently holds.

The interview with Mr. Congdon concentrated on the period September 30, 1978 through March 28, 1979. During this time period, he served as a CR0 at THI-2 assigned to Shift "C." At that time, Shift "C" consisted of the following licensed individuals:

SHIFT "C" Shift Supervisor Brian Mehler Shift Foreman Chuck Adams

! CR0 flarty Cooper CR0 Joe Congdon CR0 (in training) fiark Phillippe l

1 A sumary of the technical analysis of the leak rate tests involving Mr. Congdon is provided in Section II of this enclosure. A sumary of the

. interview with Mr. Congdon is contained in Section III of this enclosure.

The sumary of interview includes citations to the page numbers of the transcript from which the sumarized information was extracted. Overall conclusions regarding Mr. Congdon's involvement in improper activities associated with TMI-2 leak rate surveillance testing are contained in Section IV of this enclosure. ,

II. Sumary of the Technical Analysis In late 1983 and early 1984, a technical analysis of the leak rate sur- l i veillance tests performed during the last six months of operation nf THI-2 1 l was performed by the NRC. This analysis was done as technical support to the Department of Justice (D0J) in its criminal proceeding against Met-Ed.JThe results of this analysis were used in questioning Mr. Congdon during his interview. However, based upon information obtained during the 13 interviews of former THI-2 CR0s conducted to date, a reanalysis was performed during February and March 1985. The summary of technical analysis provided in this section relies on the updated 1985 analysis. The major differences between the two analyses, with respect to Mr. Congdon's tests will be explained at the end of this section. While the complete 1985 evaluation of leak rate tests at THI-2 is provided as Attachment 3 to this enclosure, a sumary of the conclusions regarding Mr. Congdon is provided here to help the reader understand the basis for the questions posed to him during his interview.

The test records show that of the 161 leak rate surveillance tests retained by the licensee during the period under investigation Mr. Congdon was involved in 28 of these tests. During the 28 tests, he was either the individual who-performed the surveillance test or was the operator on watch (i.e., the panel operator) who signed the CRO's Log for the period during which the test was conducted. The table below shows a breakdown of the overall conclusions regarding Mr. Congdon's tests. -

Breakdown of Leak Rate Tests Involving J. R. Congdon Evaluation Category Number of Tests Total number of tests on fi1e................................ 28 Tests with no apparent problems.............................. 8 Tests involving unstable plant conditions.................... 3 Tests involving the use of an unstable make-up tank level transmitter as input to the computer....................... 6 Feed and bleed operations during test........................ 4 Water additions that were not included in the calculation.... 3 Hydrogen additions to the make-up tank during test........... 4 Hydrogen or water additions during test (unable to differentiate)............................................. 2 i Tests indicating unidentified leakage in excess of the TS 11mit................................................... 2 l

Note: Four tests fall into more than one evaluation category:

Test 29 contains both unstable plant conditions and feed and bleed operations.

Test 36 contains both water and hydrogen additions during the test.

Test 42 contains both unstable plant conditions and the use of unstable LT-1.

Test 58 contains both feed and bleed operations and the use'of unstable LT-T.

As can be seen from the table above, only 8 of the 28 tests involving Mr. Congdon appear to have been conducted in accordance with the requirements and precautions of the sutveillance procedure governing the conduct of leak rate tests (SP 2301-3D1). The remaining 20 tests involve actions that violate the limits and precautions of the procedure, thus, yielding question-able or invalid results. For some tests, operator actions were taken in an attempt to manipulate or influence the outcome of leak rate test results.

The bases for our conclusion on each test are presented below.

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Three tests, #29 (10/29/78), #42 (12/01/78) and #108 (02/07/79) were performed when the plant was not in a steady state condition. SP 2301-3D1 directs that the test be performed once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady state operation. The procedure also cautions the operator to maintain the RCS and make-up system 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 and the operator should avoid additions or removal of water from the RCS and make-up system during the test. For the most accurate determination of the RCS leak rate, the initial and final conditions of reactor power, RCS temperature, pressure and pressurizer level should be identical. During test #29 there were large oscillations in Tave, ,

pressurizer level and make-up tank (MUT) level. In addition, a feed and bleed operation of approximately 800 gallons was performed during the test. ~

Test #42 was performed during a plant heat up just prior to taking the reactor critical. In addition, the unstable level transmitter (LT-1), as will be explained below, was used as input to the computer during the test.

Test #108 was also conducted during a period when oscillations were occurring in the plant caused either by power level changes or possible feed and bleed operations. The results of all three tests yield results that are below the Technical Specification limit for unidentified leakage; however, because of i unstable plant conditions at the time the tests were run, the test results are invalid.

I During the months of December 1978 and January 1979, one of the two level transmitters that provide MUT level indication had a very erratic and unreliable output. The output of one of the level transmitters drives the MUT strip chart recorder in the control room while the other level trans-mitter provides MUT level indication to the plant computer. A selector switch in the control room allowed the operator to switch level transmitters feeding the strip chart recorder and the plant computer. When the selector switch was positioned to LT-1, the strip chart recorder would be driven by LT-1 and LT-2 would provide automatic input to the plant computer for leak rate test calculations. When the selector switch was changed to LT-2, the strip chart recorder would be driven by LT-2 and the computer would receive its MUT level indication from LT-1. Because of the erratic nature of the l

l

4 output of LT-1 during this period, any leak rate tests that were perforueo with the use of LT-1 providing input to the computer must be considered questionable. Of the 54 tests conducted by all shifts during this period, l only 16 were performed with the stable level transmitter (LT-2) providing i input to the computer during the test. During this period, Mr. Congdon was involved in 7 tests, 6 of which used unstable LT-1 as input to the computer.

These tests are: #42 (12/01/78), #48 (12/05/78), #53 (12/09/78), #58 (12/12/78), #80 (12/30/78) and #86 (01/05/79). Tests #42, #48, #53 do not i appear to have been affected to a significant degree by the use of LT-1; l however, Tests #58, #80, #86 do show significant differences between the output of LT-1 and LT-2. The use of LT-1 during this period as input to the computer would result in a sw.ningless calculation of unidentified reactor coolant system leak rate whien could not demonstrate conformance with the Technical Specification limit of 1.0 gpm.

Four tests, #6 (10/04/78), #29 (10/29/78), #58 (12/12/78) and #112 (02/10/79) involve possible feed and bleed operations during the period the leak rate tests were being conducted. The limits and precautions section of SP 2301-3D1 directs the operator to avoid boration and deboration during the test. Section 6.3 of the procedure again cautions the operator not to make changes to the RCS inventory if at al possible; however, the procedure prcvides a separate data sheet to be filled out by the operator if such changes are unavoidable. The data from that sheet is to be included in the

, test calculation. Contrary to the above, in all four cases, the additional data sheet was not filled out and no inventory changes were included in the calculation. Similarly, three tests, #18 (10/21/78), #24 (10/26/76) and #36 (11/05/78) contain water additions to the MUT during the test. These water additions are also not included in the test calculation. In only one of the seven tests (#36) was the RCS inventory change, logged in the CR0's Log by the panel operator.

1 Four tests, #36 (11/05/78), #39 (11/09/78), #120 (02/15/79) and #134 .

(03/01/79) contain hydrogen additions to the MUT during the course of the leak rate test. In all four instances the hydrogen additions were logged in the CR0's Log. For tests #36, #39 and #134, the effect on leak rate tests results appears to be small. Test #36 also contained a water addition at the l beginning of the test that was not included in the test calculation. Both the water addition and the hydrogen addition were actually done on the previous watch section (Section "B"). The test was completed on Shift "C" and signed by Mr. Congdon as the operator performing the test. The MUT strip chart for test #120 is annotated with the words " Pressurized MUT." This test appears to be the test Mr. Congdon referred to in his interview as being an experiment to determine what influence hydrogen additions would have on MUT level and consequently leak rate test results. (See pages 66-69 of Mr. Congdon's 01/29/85 interview with 01/NRR). According to Mr. Congdon, the strip chart was annotated by his Shift Foreman, Chuck Adams, who was participating in the experiment. Two other tests, #126 (02/19/79) and #130 (02/26/79) contain either water or hydrogen additions during the tests.

There is nc log entry in the CRO's Log for either test; however, the MUT strip chart trace for both tests exhibit characteristics either a hydrogen addition or a small water addition.

Finally, two tests, #120 (10/18/78) and #12E (10/18/78) performed while Shift "C" was on watch, were unsigned leak rate tests indicating unidentified

leakage of 1.29 gpm and 1.32 gpm respectively. Since Mr. Cooper was the

, panel operator and Mr. Adams was the Shift Foreman during these two tests it is assumed that Mr. Congdon was the individual who ran the tests. These tests were not filed with the other surveillance tests maintained by the licensee. Instead, these tests were filed with a set of tests that lead up to the submission of LER 78-62/1T on 11/01/78. The significance of this particular LER was discussed with Mr. Congdon during his 01/NRR interview (See pages 44-51). However, Mr. Congdon was not questioned on the-two unsigned tests associated with LER 78-62/1T.

As discussed in the beginning of this section, when Mr. Congdon was interviewed by 01/NRR in January 1985, he was questioned prior to NRR's updated analysis of the 161 leak rate tests. The major revision to NRR's analysis, with respect to Mr. Congdon, involvas the six tests where unstabla LT-1 was used to provide input to the computer during the test. During the interview, Mr. Congdon was not questioned about his use of LT-1.during these tests. Also, two of Mr. Congdon's tests have been placed in a new category

" water and/or hydrogen additions" due to the inability to differentiate between the two characteristics for these tests. These differences are not considered significant from the perspective of conducting anothat interview to obtain Mr. Congdon's statement.

In sumary, the technical analysis shows that between 09/30/78 and 03/28/79 20 of the 28 tests (715) involving Mr. Congdon invclved actions that were contrary to the precautions and limitations of Surveillance Procedure 2301-3D1. These actions included: unstable plant conditions; use of an unstable MUT level transmitter te provide input to the computer; feed and bleed operations; water additions that were not properly included in the calculation; and hydrogen additions to the MUT. During the period where identified leakage was high (01/01/79 to 03/28/79), 7 of the 8 tests (88%)

involving Mr. Congdon included these same procedural errors. Based upon the high number of questionable or invalid tests, it appears that the tests were accepted as valid as long as the result was less than the Technical Specification limit, regardless of the evolutions in progress during the

. test. For some of these tests, evolutions were identified which other operators admitted utilizing to manipulate or influence the test results.

III. Interview Summary During the period under investigation, September 30, 1978 through March 28, 1979, Mr. Congdon indicated that he was primarily assigned to."C" Shift. The licensed members of his shift included: Shift Supervisor, Brian Mehler; Shift Foreman, Chuck Adams; and Control Room Operators (CR0s) Marty Cooper and himself. In addition, Mark Phillippe was an unlicensed CRO-in-training assigned to their shift. See pages 5-6.

Congdon stated that he had a very close working relationship with his Shift Foreman and his fellow CR0s. Because'the Shift Supervisor was also l responsible for the operation of TMI-1, his working relationship with the

! Shift Supervisor was not as close as the.others. He would see the Shift Supervisor periodically throughout the shift. See pag.e 7.

His working relationship with the Supervisor of Operations, J. Floyd, was not very close. He would see Floyd principally in the control room during day shift. Floyd would not give briefings to the shifts, that was usually done.

by the Shift Foreman. He could also not remember having any specific meetings with the THI-2 Plant Superintendent, J. Logan; the Superintendent of Technical Support (until December 1978) J. Seelinger; or the Station Manager, G. Miller. When he would see management personnel in the control room they would normally inquire about general plant status or ask specific questions about a particular evolutica that was in progress. See pages 8-10.

~~

In describing how his shift was organized, Congdon stated, that one man would have the panel or desk. That operator would be responsible for maintaining the CRO's Log and taking care cf the plant (panel operator). One CR0 would take charge of the ' switching and tagging" desk and control those evolutions.

The third CR0 would normally be involved in running surveillance tests.

See pages 12-13. ,

Mr. Congdon stated that the individual who was assigned to surveillance testing would normally be the individual who would initiate the leak rate test. After reviewing the test, the cperator running the test would take the test to the CR0 on the panel, inform him of the results and review the results with him. Thus, the panel operator woult' not normally run the test; however, on a normal basis he would be the individual who controlled evolutions such as water additions and hydrogen additions to the make-up tank (MUT) and he would be informed of the test results. See pages 12-13.

Since Mr. Phillippe was not a licensed CRO, Congdon stated that he was always under'the supervision of one of the licensed CR0s. The amount of direct supervision he would receive depended upon the evolution being performed.

Phil11poe could run leak rate tests himself; however, it was with the -

awareness of the other CR0s. They would normally review the results of any tests that he performed. See pages 13-14.

The individual running the leak rate test would usually inform the panel operator prior to initiating the test in order to check on plant conditions and upcoming evolutions that could affect the test. Typically, they would try to run at least one test per shift. He stated they may have run tav or three tests because it was sometimes difficult to get stable plant conditions. See pages 15-16.

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2

-7 Congdon stated that they would normally start a leak rate test at the beginning of each shift. He said that while he did not use or refer to the  !

procedure while conducting the test, he was very familiar with what the ,

procedure required and what the acceptance criteria were for the test. See l pages 16-18.

After reviewing copies of THI-2 Technical Specification 3.4.6.2, " Reactor Coolant System Operational Leakage," and TMI-2 Surveillance Procedure, 2301-301, " Reactor Coolant System Inventory," Congdon confirmed that the Surveillance Procedure was used to assure that the Limiting Condition for Operation associated with Technical Specification 3.4.6.2 was met. See pages 11-12.

Mr. Congdon was asked to describe what would happen if he ran a leak rate test and the results were not acceptable (i.e. unidentified leakage in excess of 1.0 gpm). Congdon stated that if they got an unacceptable result and they did not make an administrative mistakes, such as putting the wrong number into'the computer, or if there was not an operational reason to explain the result, such as changing power, they would imediately initiate another leak.

rate test. They would bring it to the Shift Foreman's attention and if there was no reason why it should be invalidated, they would proceed to look for reasons to support why the leakage had increased. They would dispatch Auxiliary Operators (A0s) to look for leaks and they would monitor plant parameters such as sump levels, atmospheric monitors and water inventory.

They would retain the test while the second one was being run. See pages '

19-20.

Mr. Congdon was asked if they woulu enter the Action' Statement of the Technical Specifications in a cast like he described above. Mr. Congdon said:

I consider it kind of complying with procedures to what is .

expected when you get one greater than one, but it wasn't a formal -- we wouldn't, like today, that would have been the point where you entered the action statement. You know, we would have logged it, on the end of the log, we would have put it on the board as of such and such a time, entered the action statement. But at that time, we weren't doing that.

See page 20.

It was pointed out to Mr. Congdon that the' action statement associated with Technical Specification 3.4.6.2 requires:

With any Reactor Coolant System leakage greater than any one of the above limits, excluding PRESSURE BOUNDARY LEAKAGE, reduce the leakage rate within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least HOT STANDBY within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUTDOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />. See page 21.

According to Congdon, when this situation arose, they were doing the follow-up action required by the procedure but they were not entering the Action State"*nt. Congdon did state that he believed there were times when they had received a leak rate test result that showed unidentified leakage was greater than 1.0 gpm and they had not received an acceptable result

. .g.

within the following four hours. He stated that as they approached the date of the accident it became more difficult to get results that were less than 1.0 gpm. See pages 22-23.

Congdon stated that once they received an acceptable leak rate test, the unacceptable ones were thrown away. He said that they were normally thrown away by either the Shift Foreman or one of the operators. He believed that his Shift Supervisor was aware of this practice. He believed that the Supervisor of Operations was also aware of this practice; however, could not base that on a particular event or discussion. Congdon was also asked if anyone above the Supervisor of Operations may have been aware of the practice of throwing away test results that were greater than 1.0 gpm. Congdon replied:

I'm not really sure, you know, how far up what their aware- '

ness were. But considering the frequency of this occurring, and we didn't feel like we were doing anything -- I didn't-feel like I was doing any thing wrong in discarding them, because that's the way we had always done it, I wasn't directed specifically not to do it. See page 25.

• At this point in the interview, Mr. Congdon was asked if he would agree or disagree with some of the statements made by his former shift-mate Marty Cooper. Mr. Congdon agreed with the following four statements:

1. That they had little faith in the reactor coolant leak rate test calculations that were performed to show compliance with the Technical Specifications.

2. That leak rate test results were erratic even when tests were run back to back with the same stable plant conditions.

3. It was comon practice to run leak rate tests several times per

• shift until an acceptable result was obtained. The acceptable l results were retained and the unacceptable results were thrown away.

4. That Cooper felt pressured to obtain acceptable leak rate test results on each shift; however, he did not feel that if he was unable to get an acceptable test by the end of the shift that any adverse action would be taken against him or that his competence as an operator would be called into question. See pages 27-28.

Mr. Congdon was asked what rationalization they used to accept as valid, a test result that was less than one gpm and yet not accept as valid a test result that was greater than one gpm. Congdon said that he did not have a good explanation. While Congdon did not have faith in the leak rate test itself, he stated that there were other parameters that they could monitor to give them an indication of whether the leak rate result was believable or not. Congdon said, "that was the best tool we had even though we didn't have a lot of faith in it." See pages 28-29. Regardless of the results of the surveillance test Congdon believed that the operators knew whether they had leakage or not from observing many of the other parameters in the plant. See page 30.

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.g.

Mr. Congdon stated that he thought supervisory personnel were aware of the problems operators were having. He mentioned two examples where potential sources of inaccuracy were removed from the procedure. The first was making the Reactor Coolant Drain Tank (RCDT) level an automatic input to the computer instead of a manual input. The second was the density compensation attachment that was used shortly before the accident, to correct for the actual mass that was going into the RCDT. He said this latter modification was necessary due to the high leakage they were experiencing into the RCDT from either one of the code safety valves or the PORY on the top of the 2

pressurizer. See pages 31-32.

Mr. Congdon was asked if they routinely logged the start and stop time of all leak rate surveillance tests as required by Administrative Procedure 1012

" Shift Relief and Log Entries." He stated that they logged the completion time and the results of the acceptable tests but not the unacceptable tests.

He did not believe that they were not logging the start times in order to hide the fact that they were running so many tests. He was nev'er instructed by supervisory personnel not to log in the results of bad tests. Congdon stated:

I didn't feel that we were doing anything wrong at the time.

Obviously today I would look at it entirely differently.

But at that time, it never occurred to me that this was incon-sistent or be the improper way of doing it." See pages 33-35.

- As best he could recall, Mr. Congdon believed that whenever he received the results of a leak rate test, he would show the results or discuss the results of the test with his Shift Foreman, Chuck Adams. When the tests were

> discarded, it was with the knowledge and concurrence of Adams. See pages 38-39.

l Mr. Congdon stated that there were times when a satisfactory leak rate test .

result was not obtained on a shift and that result was discussed at shift turnover. Usually, the Shift Foreman would point out and emphasize that they needed to keep working on the leak rates to try and get a satisfactory one.

When this occurred Congdon did not recall any discussion about why a plant shutdown had not been commenced. See pages 39-40.

Mr. Congdon was asked to review a copy of Licensee Event Report (LER) 78-62/1T. After reviewing the document, Mr. Congdon stated that the LER was initiated by the Company following an incident in which an NRC inspector found several leak rate surveillance tests lying in the Control Room that indicated the unidentified leak rate was in excess of the requirements of the Technical Specifications. It was pointed out to Mr. Congdon that the narrative section of the LER stated the event was nused by a misinterpre-tation of the requirements of the Technical Specifications and that appropriate personnel would be instructed on the requirements of the Technical Specifications and the requirement to imediately invoke the Action Statement when the provisions of the Limiting Condition for Operation are not met. Mr. Congdon stated that at the time they reviewed documents of this nature by reviewing a " required reading book" in the control room. The book contained many documents that they had to sign-off on. The LER may hau been one of those documents; however, he did not recall this particular LER as standing out in his mind as far as having any impact en the way he conducted I

t

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leak rate surveillance tests. See pages 44-46.

Other than the document being placed in the required reading book, Mr. Congdon could not recall any specific instruction he received as a result of the LER. Mr. Congdon was then advised that when Mr. Cooper was i interviewed on this matter, Mr. Cooper stated that the only instruction he could recall was being told to ensure that bad leak rate tests were thrown away and not left lying around the control room where the NRC coul.d find l them. Mr. Congdon said that he believed an instruction to that effect was '

put out at one of their shift briefings. He could not be sure who the individual was who made the statement, but he believed it may have been his Shift Supervisor, Brian Mehler. He could not recall for sure, but he believed that his Shift Foreman, Chuck Adams was present at the time. See pages 47-51. Mr. Congdon did not know if that type of instruction was given to other shifts. He did not recall that being discussed at any point by Mr. Floyd, Mr. Logan, Mr. Seelinger, or anyone else at a higher, level of authority. k pages 49, 51.

When Mr. Congdon was asked to describe the type of pressure he felt to get a good leak rate test result, he responded by stating:

1 I think. the type of pressure I was referring to would be i just an innate type pressure associated with the job in itself. There is a lot of pressures when you are at power and operating to do all that we had to do to operate the plant safely and to meet all our obligations. And the difficulty getting leak rates irritated that, because it just made that unnecessary pressure because it was always surveillances being run, a lot of things going on that required your attention.

So the pressure to get a good leak rate was there, but it -

wasn't something that, don't do anything else but get a

! good leak rate. It wasn't -- it was placed -- it was brought to our attention like in a shift briefing, you

know, we need a good leak rate. Let's try to get one. And this was in our mind. We were trying to comply with that, trying to do what were supposed to do and still do every-thing else that had to be done in the course of that particular shift. See pages 53-54.

When asked if financial considerations played a part in keeping the plant operating with high identified leakage, Mr. Congdon stated that the operators believed their job was to operate the plant safely and generate electricity.

From that point of view, it was a matter of pride to keep things operating safely and doing your job. He said, you would not want to be the one that shut the plant down unnecessarily, but there was never an attitude that "we wanted to violate safety issues for the sake of raking a buck." See pages 54-55.

Mr. Congdon was asked if operating with high identified leakage was a concern for the operators. He stated that they were concerned about it since it certainly wasn't normal and it was certainly not the way they wanted it to be. It made the job of the operators much harder since they were frequently

, pumping down the drain tank, frequently making up water, and frequently recirculating the pressurizer to equalize boron concentration. He stated that all of these additional things added to their responsibilities on a shift which made it more difficult to do the job in a professional and safe manner. He stated, however, that it was a situation that they believed they could live with in a safe manner, since it was controlled leakage and they knew where it was going and it was not affecting the health and safety of the public. He said that they had identified the problem and it was scheduled to be fixed at the next planned outage, after TMI-1 was back on the line from refueling. See pages 55-57. Mr. Congdon was asked if it had ever gotten to the point onliTs shift where the operators believed that the plant should be shutdown and not wait for the planned outage. Mr. Congdon said that he did not recall that being discussed, but he thought that "we shared that attitude to one degree or another." See page 58. Mr. Congdon believed that this attitude was probably sharedTf his Shift Foreman and Shift Supervisor. See page 59. .

Next Mr. Congdon was questioned about hydrogen additions to the MUT and its possible affect on leak rate surveillance tests. 'Mr. Congdon stated that hydrogen was added frequently to the MUT for use as an oxygen scavenger. He said for a great deal of the time, hydrogen was added locally by the A0s, since the capability to add hydrogen from the control room was not functioning properly. Mr. Congdon stated that hydrogen would normally be added if either pressure in the MUT was low in the operating laand or if primary chemistry indicated that oxygea concentration was high in the reactor coolant system. See page 62-64.

Mr. Congdon stated that back in 1978/79 he did not consider adding hydrogen '

to the MUT to be a chemical addition to the RCS. Thus, he did not consider it a procedural violation to add hydrogen during a leak rate surveillance test. He would log the addition in the CRO's Log. He said it was not required to log hydrogen additions; however, he would try to log as many -

evolutions as he could so that other people reviewing the log would know what occurred. See pages 65-66.

Mr. Congdon stated that M some point, although he could not recall when, he became aware that the adCJon of hydrogen to the NUT could affect MUT level indication. He said sometimes the addition had no affect on level; sometimes it would make the level go up; and sometimes it would just dampen out the normal saw tooth trend of the level recorder. He believes he became aware of the phenomenon from general discussions with other operators. At one point, Mr. Congdon stated, his shift ran an experiment to determine if hydrogen would influence the leak rate test results. He stated that he and his Shift Foreman, Chuck Adams ran the experiment. Mr. Adams actually annotated the MUT strip chart where hydrogen was added. He could not recall the date of the experiment, but believed it was sometime in 1979, possibly in February. ,

! NOTE: The test Mr. Congdon referred to appears to be 1 Test #120. The test was performed between 2026 and 2126 on February 15, 1979. The test was performed by Mr. Cooper. Mr. Congdon was the panel operator and Mr. Adams was the Shift Foreman.

Mr. Congdon could not recall the results of the experirnent; however, he

i believed that they may have been inconclusive. See pages 66-69.

1 At this point in the interview, Mr. Congdon was provided a package of material associated with the leak rate tests he was involved in during the

! period being investigated. The package included a sumary sheet, leak rate surveillance test data sheets, extracts from the CRO's Log and the Shift Foreman's Log, and copies of the strip chart recorder trace for MUT level indication. After explaining the material in detail, Mr. Congdon was allowed to review the package in private with his attorneys. See pages 69-77.

Following Mr. Congdon's review of leak rate test materials, he was questioned once again about his knowledge and use of hydrogen additions to the MUT to influence leak rate surveillance tests. Congdon stated:

I did add -- have added hydrogen in the course of a leak .

rate. At the time, I didn't -- I don't know how many times but I'm sure I did, but at that time I didn't see anything wrong with doing that. I didn't consider, as you mentioned before, hydrogen being a chemical so I didn't feel that I was violating the procedure. I didn't have a clear perception of what effect that was having on the indicator.

Sometimes it had no effect. But I am sure there were times when I did add hydrogen in hopes that it would enhance the

, response....Lajnd hence the results." (Emphasis added). see

, page 79.

l Congdon was asked if his imediate supervisors, Chuck Adams and Brian Mehler were aware that hydrogen was being used on occasion to try and assist in getting acceptable leak rate results. Congdon believed snat both individuals were aware; however, he was not as sure about Mehler's knowledge, since he did not have as close comunications with Mehler as he did with Adams and the other CR0s on his shift. Congdon also believed that both his fellow CR0s, Marty Cooper and Mark Phillippe were aware hydrogen additions were being made

- to influence leak rate test results. See pages 80-83. Congdon stated his belief that these hydrogen additions were not just limited to his shift; however, he could not say how many shifts or how many other operators were involved. See page 84.

Although Mr. Congdon stated, at the time he did not believe he was doing anything wrong when he added hydrogen, since it was not precluded by the procedure, looking back upon those events today, he admitted that they were wrong and certainly not something that he would do today. See pages 89-92.

Mr. Congdon was then questioned regarding his April 10, 1980 interview with the NRC concerning leak rate testing irregularities. During the interview, Mr. Congdon admitted that he was aware of the effect hydrogen could have on leak rate tests; however, he stated that his addition of hydrogen during tests was not a willful manipulation of the test. Mr. Congdon was asked to explain how he could rationalize his actions that way. Mr. Congdon responded by stating:

I think that was about a year after the accident. And to give you a little background, you know, we were called in --

I was called in for interview. I had heard a little bit

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l

. 13 l

( , abcut what the nature of the interview was. I had no idea really what the substance of it was. And I really hadn't thought about leak rates or hydrogen additions, because we had been very -- it had been a stressful year as far as our ,_

work st the plant. I had been doing a lot of hours and .

hadn't really been thinking about this period of time prior to the accident.

And in that interview when, from where I was going into it, really not having thought about it too much, I was presented with a lot of documentation supporting the allega. ton that I was doing something that was obviously wrong. It was obviou' sly documented here. At that point I was -- quite literally, I was in shock, because I hadn't at that moment

, , really felt that I -- or viewed my behavior as anything but the best that I could possibly do.

I thought that I was a good operator. I felt that I was com-petent. And I felt like I was doing the job to the best of my ability. I really didn't view any of my actions,

. including the area of leak rates, as unprofessional or .

anything less than the best I could possibly do. I tried to be very conscientious as an operator. And when confronted with these allegations and the documents that on the surface, you know, supported it I was very shocked. And from that point out. I really didn't know how to confront it or how to

( challenge it, because I hadn't really prepared for it.

And I think a lot of the rationalization was just out of the stress of that confrontation and that all of a. sudden here are some people that really think I was a lousy operator and did things to, deliberately falsify records and to falsify safe conditions in the plant.

I really didn't have that vision of myself at that point, that I had done pnything less than operate to the best of my l ability. -

Over the years I've grown as far as my awareness of what is tne intent of how to operate and what the intent of the specs are and procedural compliance, and lo'oking back at it I can view that behavior as certainly unacceptable in today's light. And I never would -- if I had the attitude then that I have today, I wouldn't have viewed it that way.

And I can't really explain why I treated it that way at that time other than just out of ignorance or out of just -- I don't have an explanation for it.* See pages 95-96.

e

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~

14 J

Next, Mr. Congdon was questioned on water additions during the performance of .

leak rate tests. Mr. Congdon stated that to the best of his knowledge, he did not deliberately add water during the course of a leak rate test to affect the outcome of the test. Congdon said that he tried very hard not to add

( water during the test; however, if he had to add during the test, he would include the amount of the addition in the leak rate test calculation. See ~

page 107.

! Mr. Congdon stated that if water were added and not included in the calculation, it was caused by a mix-u test and the individual on the panel.p between the individual He said whenever a leakrunning rate testthe was in progress, he would try to put a note on the MUT 1evel indicator in order to remind the panel operator that a test was in progress g pages 107-108.

-s---Mr. Congdon was asked if during a water addition he was aware t' hat the-amount-of water added in gallons, as read off the totalizer, could be different than the amount of water added, as shown by the change in MUT level indication.

Mr. Congdon stated he was aware that there was an inconsistency; however, he did not know about it at the time. This was knowledge he had picked up subsequent to the accident. M pages 109-113.

NOTE: NRR's technical analysis su'p ports Mr. Congdon's testi-l mony that he did not take advantage of this inconsistency l between instrumentation in order to manipulate leak rate test i results (i.e., underrecorgled water additions),

l Following a detailed discussion of several'1eak rate tests involving possit l water additions, Mr. Congdon still maintained that he.did not make water j additions to the MUT with th6 intent of altering the leak rate test results.

i

• Mr. Congdon did not agree with the conclusion of the technical analysis on

l. some of the tests. He did not believe that some of the tests exhibited the

. characteristics of a water addition. It was explained to Mr. Congdon that it a

was possible that some of the tests originally categorized as water additions, could be hydrogen additions. Unless there is an entry in the CRO's Log to differentiate the two, the HUT strip chart trace for a hydrogen addition could look very similar to a water addition, provided the water was added in small amounts. See pages 117-134.

Mr. Congdon said that he was not aware until recently that water additions

, may have been used to alter leak rate test results. He agreed that while j hydrogen additions were not explicitly prohibited by the procedure, the addition of water to the MUT without recording it and not including it in the test calculation would have been a blatant violation of the procedure for conducing leak rate tests. He stated that he was not aware of any individual making. water additions for this purpose. He also stated that he was not aware of any discussions with other operators about their use of water additions to influence leak rate test results. See pages 129-130.

In concluding the interview, Mr. Congdon stated that there was no additional information he could provide regarding his involvement or the involvement of others in the falsification of leak rate test data at THI-2. See page 135.

IV. Conclusions Throughout Mr. Congdon's interview he appeared to answer questions in an honest, straightforward manner. His testimony was consistent with the information provided by many of the other Control Room Operators at THI-2 that have been recently interviewed by DI/NRR. Mr. Congdon's statements were also consistent with the Department of Justice's Statement of Facts and other evidence developed by 01 during its earlier THI-2 Leak Rate Investigation.

1 During the course of the interview, Mr. Ccagdon provided the following i information:

1. Congdon's shift tried to run at least one leak rate test per watch. He-stated they may have had to run two or three tests during a watch because it was sometimes difficult to get stable plant conditions.

2. Mr. Congdon stated that when leak rate test results were greater than the limit allowed by the Technical Specifications, they would initiate the follow-up actions required by the procedure, including running backup tests and looking for the source of the leakage; however, he

- stated that they did not enter the Action Statement of the Technical Specifications.

3. Once an acceptable leak rate test result was obtained, the unsatisfactory test results would be thrown away by either the operator or the Shift Foreman. He believed that his Shift Supervisor and the Supervisor of Operations were both aware of this practice.

4. Mr. Congdon believed that there were times when they had received a leak rate test result that showed unidentified leakage was greater than the one gpm limit and they did not receive an acceptable result with the following four hours. He stated that as they approached the date of the accident, it became more difficult to get acceptable leak rate test .

results.

- _ . . . .,_ . , - - - , .-- . - - ,,,-,_.,,n_,-- , _ . - , , - - - -- _ _ _.----- --

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Note: The Action Statement of Technical Specification 3.4.6.2 requires:

If Reactor Coolant System Unidentified Leakage is greater than i

one gpm reduce the leakage rate within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least HOT STANDBY within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUTOOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.

5. Mr. Congdon agreed with the statements of his former shift-mate, Mr. Cooper, that the operators had little faith in the RCS leak rate test calculations that were perfonned to show compliance with the Technical Specifications, and that test results were erratic even when tests were run back to back with the same stable plant conditions.

Mr. Congdon also stated that regardless of the results of the surveillance test, he believed that the operators knew whether they had leakage or not from observing many of the other parameters in the plant.

6. Mr. Congdon stated that they routinely logged the completion time and the results of the acceptable tests but did not log the unacceptable tests. He denied that they were not logging the start times of all

. tests in order to hide the fact they were running so many tests. He was never instructed by supervisory personnel not to log in the results of bad tests. Note: Administrative Procedure 1012 required that the test title, test number, and the start and completion times of all surveillance tests required by the Technical Specifications be logged in the CRO's Log. ,

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7. Mr. Congdon stated that LER 78-62/1T did not have any impact on the way

. . leak rate tests were conducted on his shift. Following issuance of the LER, Mr. Congdon did recall being told to ensure that bad leak rate test results were thrown away and not to leave them lying around the control room where the NRC could find them. Although he was not positive, he recalled that his Shift Supervisor, Brian Mehler was the individual who provided that instruction. He also believed that his Shift Foreman, ~

Chuck Adams was present at the time that instruction was given. Note:

Mr. Congdon's *ecollection of this instruction is consistent with state-ments made by Mr. Cooper during his 01/NRR interview on September 28, 1984. Note: LER 78-62/1T stated that leak rate surveillance test problems were caused by a misinterpretation of the requirements of the Technical Specifications and that appropriate personnel would be instructed on the requirements of the applicable sections of the Technical Specifications and the requirement to innediately irvoke the applicable Action Statements when the provisions of the Limiting Conditions for Operation were not met.

8. Mr. Congdon stated that he did feel pressure to get a good leak rate.

He said that it would be brought to their attention at shift briefings that they needed to get a good leak rate test. He said that they were trying to comply with that direction and still get everything else done that they had to complete on the shift.

9. Mr. Congdon said that the operators did not like having to operate the plant with high identified leakage, since it led to many other operational problems while they were on watch. He stated, however, that they considered it a situation that they could live with in a safe manner. When Mr. Congdon was asked if the operators on his shift i,-.-------y- . . - . , - , , --w -- --w,~ . - - - , , - - + - " - - - .- _ - - - - - - - - - - - - - , 3-,- --ve+=------=---*--------r- - - - - ' - - - - ' - - - ' - - - - - - - - - - - - - '

.{ bel'ieved that the plant should be shut down to correct the problem and not 'w4it for the planned outage, Mr. Congdon stated "we shared that attitude' to one degree or another." He also believed that this attitude was shared by his Shift Foreman and his Shift Supervisor. -,

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10. Mr. Congdon stated that sometime around February 1979, he became aware of the fact that hydrogen additions to the MUT could influence MUT level and hence leak rate test results. He described an experiment that was un on his shift by the Shift Foreman to determine if the hydrogen additions could influence MUT level and hence test results. -

11. Mr. Congdon stated that at the time, he did not consider hydrogen additions during leak rate tests to be a violation of the procedure.

Yet, he admitted that he added hydrogen to the MUT during~1eak rate I

tests with the intent of influencing leak rate test results. He stated I that adding hydrogen did not always produce the same effect. He

- believed that the other CRos on his shift were aware that this was being done and that both his Shift Foreman and his Shift Supervisor were also aware that hydrogen was being added during tests for the purpose of maniculating test results. Although he could not provide any details, he did not think that hydrogen additions were limited to just their shift.

12. Mr. Congdon stated that to the best of his knowledge, he did not intentionally add water to the MUT tank for the purpose of influencing

' ( leak rate test results. If water additions did occur and were not included in the calculation, he felt it may have been caused by miscomunication between the operator performing the test and the operator on the panel. Mr. Congdon stated that while he did not consider hydrogen additions to the HUT during leak rate tests a ,

procedural violation at the time, he would have considered an intentional, unaccounted for water addition during the leak rate test a blatant violation of the procedure.

13. Mr'. Congdon was not aware until after the accident that operators may have been adding water to the MUT in an attempt to influence leak rate tests. He did not recall any discussions with other operators that they were making water additions for that purpose.

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l It iiciear from his testimony, tha1; while he was involved in activities that violated approved procedures and

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Technical Specifications, his actions were comen practice among operators at TMI-2 and that his first line supervision and possibly middle level manage-

- ment were aware of these practices and openly sanctioned these activities.

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. s "N0iE: This enclosure discusses information that is maintained in the NRC's i Privacy Act System of Records (NRC-16). This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO. Internal access and distribution should be on a "need to know" basis.

Enclosure 2 -

Background

On February 1,1985, an interview was conducted with Mr. Joseph Congdon, a Senior Reactor Operator at Three Mile Island Nuclear Station, Unit 2 in order to determine Mr. Congdon's understanding of his responsibilities for the safe operation of the plant and his comitment to those procedures and operating principles necessary to carry out those responsibilities. Participating in '

the interview from the NRC were William Russell, Deputy Director, Division of '

Human Factors Safety and Leonard Wiens, Senior Examiner, Opera' tor Licensing Branch. Mr. Smith B. Gephart, an attorney representing Mr. Congdon, was also present at the interview.

' In addition to the interview with Mr. Congdon an interview was conducted with Mr. Congdon's supervisor on January 31, 1985. The Supervisor interviewed was:

Name Position / Title Sandy Levin Site Operations Director Section II provides a sumary of the interviews with Mr. Congdon and the supervisor identified above. A sumary of coments provided by the NRC Resident Inspectors is also included.Section III provides an overall conclusion regarding Mr. Congdon's current perfomance. .

II. Interview Sumary Mr. Congdon appeared to be a very conscientious, dedicated operator. He seemed to be sincerely comitted to cperating the plant safely and in accordance with all procedures and regulations. During the interview, he displayed a quiet, confident attitude, and always seemed to logically think through any situation in which he was placed. He demonstrated a thorough knowledge of plant procedures and technical specifications, and his answers indicated a significant amount of operational experience. The overall impression was of an experienced operator who used good operating practices on a daily basis.

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III. Conclusion e

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Enclosure 5 UNITED STATES ,

[ h NUCLEAR REGULATORY COMMISSION s seamweesorom.o.c.senes k.....]! December 3,1984 l

MEMORANDUM FOR: Harold R. Denton,' Director '

Office of Nuclear Reactor Regulation l THRU: Hu h L. Th son, Jr., Director Di ision o uman Factors Safety 1 FROM: William T. Russell, Deputy Director Division of Human Factors Safety

SUBJECT:

RESULTS OF JOINT NRR/0! INVESTIGATION AND EVALUATION OF MARTIN V. COOPER -

1  : -

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)

Reference:

1. Memorandum from S. J. Chilk (SECY) to B. B. Hayes (01)

) and W. J. Dircks (ED0), dated April 2, 1964,

Subject:

Staff Requirements-Discussion of Pending Investigation-TMI -

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

Subject:

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

3. Letter from H. R. Denton (NRR) to M. V. Cooper (SRO San Onofre 2/3) dated May 30, 1984

Subject:

Request for t

Information Under 10 CFR 55.10(b) .

! 4. Letter from M. V. Coo

' H. L. Thompson (DNFS)per (SRO dated July San

Subject:

2, 1984, Onofre 2/3) to

. Response to Reference 4 The purpose of this memorandum is to document the results of the joint 01/NRR investigation and evaluation of Mr. Martin V. Cooper, currently a Senior l Reactor Operator at San Onofre, Units 2 and 3, and to provide a recomendation regarding whether his current Senior Reactor Operator's license should be revoked, modified, or suspended under 10 CFR 55.50 due to his involvement in preaccident leak rate testing irregularities at THI-2.

NOTE: This memorandum and Enclosure 1 discusses information which is the su5' Ject of an ongoing CI investigation. This memorandum and Enclosure 2 discusses information that is maintained in the NRC's Privacy Act System 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.

S , " lO l i J 4pio

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Harold R. Denton December 3, 1984

Background

As a 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 leak rate tests at TMI-2 and refer back to OI those matters which required further investigation. .The results of NRR's review was provided in Reference 2. The review detemined that follow-up investigation by OI and further evaluation by NRR was needed in the case of seven licensed operators. Of the seven individuals identified in Reference 2, four are currently licensed at TMI-2, two are licensed at Waterford 3 and one is licensed at San Onofre 2 and 3. At a follow-up Comission meeting on May 23, 1984. NRR proposed joint O!/NRR investigations and evaluations of these individuals. Subsequently, NRR issued letters to the seven individuals under 10 CFR 55.10(b) requesting additional infomation regarding current perfor-mance. Based upon an investigation into the individuals' past involvement in l

improper activities at TMI-2 and an evaluation of the individuals' subsequent performance, NRR would recomend what action, if any, should be taken against the identified individuals.

! ' Past Involvement in TMI-2 Leak Rate Testing Irregularities On the morning of September 28, 1984, a joint 01/NRR interview of Mr. Cooper was held in San Clemente, California. The interview was conducted under oath and in the presence of Mr. Cooper's personal attorney. The purpose of the

interview was to detemine Mr. Cooper's role in improper activities associated with reactor coolant system leak rate surveillance testing at TMI-2 prior to the accident on March 28, 1979. At that time, Mr. Cooper was i a licensed reactor operator (RO) and served as a Control Room Operator (CRO) l on shift "C." A detailed evaluation of Mr. Cooper's interview is included ars j Enclosure I to this memorandum.

. Mr. Cooper confirmed that preaccident leak rate testing irregularities took place at TMI-2. Mr. Cooper admitted his involvement in activities that were in violation of approved procedures and the intent of the THI-2 Technical Specifications. While he admitted knowingly adding hydrogen to the makeup tank during periods in which leak rate tests were being conducted, he denied that his motive for the hydrogen additions was for the express purpose of manipulating the leak rate test results. According to Cooper, he only added hydrogen to the makeup tank during a leak rate test if hydrogen pressure was low in the operating band. Cooper also denied that he intentionally added water to the makeup tank during leak rate tests without including the .

addition in the leak rate test calculations. This is in conflict with technical analysis of the leak rate test records, which show unrecorded water additions. Cooper's statement that he did not intentionally manipulate leak rate test results is not supported by other evidence.

Other aspects of his testimony indicate first line supervision and middle level management at THI-2 were knowledgeable of the difficulties operators were experiencing with leak rate surveillance testing and took little er no action to correct the situation. While Cooper's actions in many cases were not in accordance with procedure, these actions were apparently cormon

l 1

l Harold R. Denton December 3,1984 practice among operators at TMI-2. In most cases, these actions were known to be occurring by his first line supervision, and he believes, also by

! middle level management.

Current Performance On the afternoon of September 28, 1984, NRR conducted an interview and oral examination of Mr. Cooper, currently a Senior Reactor Operator at San Onofre Nuclear Power Station, in order to determine Mr. Cooper's understanding of his responsibilities for the safe operation of the plant and his commitment to those procedures and operating principles necessary to carry out those responsibilities. Interviews were also conducted with Mr. Cooper's super-visors on September 26 and 27, 1984. A detailed write-up of Mr. Cooper's

- current performance is contained in Enclosure 2 to this report. -

Mr. Cooper appeared to be a very conscientious and knowledgeable operator.

His commitment to operate the plant safely and in accordance with all procedures and regulations seemed to be sincere. He demonstrated a thorough i knowledge of plant procedures and Technical Specifications and the ability to use them. He presented himself as a forceful supervisor, willing to direct subordinates, accept responsibilities for his own actions and oet thinos done on his shift.

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Conclusions During the period Mr. Cooper was licensed as a Control Room Operator at TMI-2 prior to the accident, he improperly performed leak rate surveillance testing by knowingly not following procedures. He has admitted his involvement in these practices; however, he continues to deny that he intentionally manip-ulated or falsified leak rate surveillance test records. While there is evidence that he knowingly violated procedures and that his actions were known by him to effect leak rate test results, the evidence is not conclusive.

While Mr. Cooper has admitted his involvement in improper activities, it appears clear from his interviews that he now knows these actions were wrong and has subsequently developed a much more thorough understanding of his duties and responsibilities as a licensed operator.

Mr. Cooper is the first of seven operators licensed at TMI-2 prior to the

Harold R. Denton December 3,1984 accident who are undergoing a similar joint O!/NRR investigation and evaluation. It is possible that during the remainder of these investigations, additional evidence could be developed regarding Mr. Cooper's preaccident activities at TMI-2 that were not considered in this report. ,, ..

.. I bel'feve that there is reasonable assurance that Mr. Cooper has and will continue to fulfill the terms and conditions of his current Senior Reactor Operators' license. I..therefore, recomend that no enforcement action be taken under 10 CFR 55.50 against Mr. Cooper for his past involvement in improper activities associated with preaccident reactor coolant system leak rate surveillance tests at TMI-2. .

ddhb T hMll---

William T.' Russell Deputy Director Division of Human Factors Safety Office of Nuclear Reactor Regulation

Enclosures:

As stated cc: B. Hayes i K. Christopher 1

1

4

, NOTE: This enclosure discusses information which is the,sub' ject of an ongoing OI investigation. This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO or the Director 01. Internal access and distribution should be on a "need to know" basis.

Enclosure 1 Past Involvement in TMI-2 Leak Rate Testing Irregularities I. Background On September 28, 1984, a joint Office of Investigations (01)/ Office of Nuclear Reactor Regulation (NRR) interview of Martin V. Cooper was held at the Seahorse Hotel in San Clemente. California. The purpose of the interview was to determine Mr. Cooper's role in improper activities associated with Reactor Coolant System (RCS) leak rate surveillance testing at ,Three Mile Island, Unit 2 (TMI-2) prior to the accident on March 28, 1979. Present during the interview representing the NRC were: Keith Christopher, Directo,r, l

Office of Investigations Region I; William Russell, Deputy Director.

4 Division of Human Factors Safety; and Robert Capra, Technical Assistant, Division of Systems Integration. Representing Mr. Cooper at the interview was his personal attorney, Michael McBride of the law firm LeBoeuf. Lamb, Leiby and MacRae, Washington, D.C. A copy of the transcript associated with this interview is provided as Attachment 1.

Mr. Cooper is currently employed by Southern California Edison Co. as a licensed Control Room Supervisor at San Onofre, Units 2 and 3. Mr. Cooper

' has been employed at San Onofre for approximately one and a half years. -

Prior to his current employment, Cooper was employed by General Public i

Utilities (GPU) and Metropolitan Edison Company (Met-Ed) at THI-2.

Mr. Cooper was originally hired by Met-Ed as an Auxiliary Operator (AO) and

, worked in that capacity at TMI-2 for approximately one year. He received his

! Reactor Operator's (RO) license from the NRC in the sumer of 1978. From i that period up to the date of the accident, Cooper served as a Control Room

. Operator (CRO) on Shift "C" at THI-2. Following the accident Cooper l continued to work at THI-2 receiving his Senior Reactor Operator's (SRO) license in March 1980. Cooper served as both Shift Foreman and Shift Supervisor at THI-2 until he terminated his employment at THI-2 approximately November 1962.

The interview with Mr. Cooper concentrated on the period September 30, 1978 through March 28, 1979. During the majority of this timeframe, Mr. Cooper's shift consisted of the following individuals:

Shift "C" Shift Supervisor Brian Mehler Shift Foreman Charles Adams CR0 Joseph Congdon CR0 Martin Cooper CR0 (in training) Mark Phillippe Mr. Cooper and Mr. Congdon were previous;y intervised on this subject on April 10, 1980 during a joint investigation into tre "Hartnan Allegations."

Copies of the reports of these interviews are in::luded as Attachments 2 and 3 respectively, to this enclosure.

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.. s -

I A technical analysis of the TMI-2 leak rate surveillance records was performed by Dr. Jin Chung of the Office of Inspection and Enforcement, Region I. This analysis was originally done as support to the Department of Justice. The results of Dr. Chung's analysis were utilized in questioning Mr. Cooper during this interview. A review of the test records show that of the 156 leak rate surveillance tests retained by the licensee, during the period under investigation, 29 involve Mr. Cooper. During these 29 tests, Mr. Cooper was either the CR0 who signed the surveillance test record or he was the CR0 who signed the CRO's Log for the period during which the test was

conducted. Of the 29 tests involving Mr. Cooper, Dr. Chung's analysis identifies 15 tests involving possible water and/or hydrogen additions to the

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makeup tank during the one hour time period in which the leak rate tests were conducted. This includes 13 possible water additions and 4 hydrogen additions (2 hydrogen additions were combined with tests that involved possible water additions). A sumary of leak rate tests at TMI-2 involving

Mr. Cooper, along with the surveillance tests sheets, CR0 Log extracts, and 2

makeup tank strip charts for the 15 questionable tests, are included as j

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Attachment 4 to this Enclosure.

A sumary of the interview with Mr. Cooper is provided in Section II below.

A citation to the page number of the transcript in which this information was l

discussed is also provided. Overall conclusions regarding Mr. Cooper's involvement in improper activities associated with TMI-2 leak rate surveillance testing is contained in Section III.

l II. Interview Sumary In describing how his shift was organized during the 1978/1979 timeframe, 1 Mr. Cooper stated one CR0 was assigned duties as the panel operator, where J the CR0 Log was kept. This individual was in overall charge of operations on

'l the shift. A second CR0 was assigned duties as the " switching and tagging" operator and was in charge of surveillance tests for the shift. If a third-CRO, not in a training status, was assigned to the shift, this individual would perform surveillance tracking duties. See pages 12 and 13. On a

. routine basis, at the beginning of each shift 7 e operators would perform a calimetric check of the Nuclear Instrumentation, which took about 10 minutes and then would comence a one hour leak rate test. See page 13. Although the Technical Specifications (TS) required a satisfactory leak rate test only once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, it was comon practice to try ani obtain a satisfactory leak rate test every shift (i.e., every eight hours). There were times when leak rate tests had to be run several times a shift until one with a satis-factory result (within the 1 gpm limit for unidentified leakage required by the TS) could be obtained. See page 15. If leak rate tests came out bad (greater than 1 gpm or a large negative number) a new leak rate test was started and the bad leak rate test would be thrown away. See page 16.

According to Cooper, the logic for throwing away bad tests'and accepting good tests as valid was that operators could tell from looking at other instru-mentation and keeping the plant stable that they had not developed t leak.

Cooper had little faith in the calculation performed by the computer because for the same plant conditions, the results were erratic. The leak rate test was not telling the operators what the plant was really doing. See pages 16 and 17. Cooper stated that it was comon practice to throw away bad leak rate tests. He did not recall being specifically instructed by supervisors to throw bad leak rate tests away, but he was confident that it was ccmm:n

3-practice on all shifts. It had been the operating policy, ever since Cooper was licensed. See pages 18 and 19.

Cooper was questioned regarding his interpretation of the TS associated with leak rate surveillance testing. Accordir,g to Cooper, once a satisfactory leak rate test was obtained, operators had 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in which to obtain another satisfactory leak rate test before having to enter the required action statement of the TS. Cooper said that was the interpretati'on of the requirement, regardless of how many bad leak rate tests were obtained in the interim. Cooper did not know who started that interpretation but that was the general practice. He recalled that everyone followed that practice. See pages 18 and 19. Cooper stated that operators were required by TS to perform

- this surveillance every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in order to keep the plant on the line. In retrospect. Cooper said "[W]e were trying to comply with the letter of the specification, and looking back on it, we really weren't complying with the spirit." Cooper indicated "I have a new understanding of how all this works now. At the time I had a different understanding and I thought-it was perfectly okay so long as you got one leak rate satisfactory every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />,

_ and we had met the regulations." See pages 19 and 20. Cooper was questioned about whether there was any change in interpretation of that policy after the i

October 18, 1978 incident in which an NRC inspector found several bad leak rate tests lying around the control room ar.d inquired why the operators had

,' not entered the action statement of the Technical Specifications. As a result of that incident, the licensee submitted a Licensee Event Report (LER) l to the NRC on November 1, 1978 (LER 78-62/1T). According to the LER the j incident was caused by a " misinterpretation of the requirements of the T.S."

l -

The LER further stated:

"The appropriate personnel will be instructed on the re-quirements of the applicable .ections of the T.S. and the requirement to imediately invoke applicable action state-ments when the for operation] provisions are not met."of the LCOs [ limiting conditions ,

In recalling the October 18, 1978 incident Cooper stated:

"My recollection, you know, I wasn't there when it hap-I pened, and the way I heard about it is we were coming on l in the evening relieving B-shift, and they told us about i

the NRC inspector Don Havercamp finding these things lying on the desk by the computer, and part of the turn-over from the control operator I was relieving that this had happened. That from now on if you are throwing away bad ones, make sure you throw them away, just don't leave them lying around." See page 64.

When asked if his interpretation, with respect to needing a good leak rate l test only once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, regardless of how many bad leak rate tests were obtained in the interim, had changed following the October 18, 1978 incident, Cooper responded, "That was carried forward, it was the same, and I believe that is the general interpretation in the department and nothing ever changed." See page 68.

According to Cooper it was difficult at times to get good leak rate test results. There was no pattern, " rhyme or reasen" as to why it was hard one

4 time and easy the next. Cooper stated it was comon knowledge at the supervisory level that operators were having difficulty obtaining good leak rates. Cooper's Shift Supervisor, Brian Mehler, was aware that they were I having a problem with getting good leak rates, and that the results were l inconsistent. Mehler was aware that unsuccessful tests were run and that additional tests had to be initiated. Cooper stated that there was a lot of pressure to get good leak rate test results. There was constant questioning by the shift supervisors regarding leak rate test results. See pages 24 and

25. According to Cooper, although there was pressure to get a good leak

, rate, he did not feel that the pressure was at his level. He stated he never had the feeling that if he did not come up with a good leak rate, that

something " bad" was going to happen to him or that it would cast doubt on his competence as an operator. See pages 27 and 28.

Cooper was also questioned regarding the motive for not logging both the start and stop times of leak rate tests as required by TMI Administrative Procedure (AP-1012). Cooper said that, although the requirement existed.

- operators did not normally log the start and completion times for tests that l were run once or more per shift, such as leak rate tests. Only completion times were logged. Cooper stated, however, that not logging both times was j not acceptable to the QA organization at TMI. When questioned why i

unsuccessful tests were not logged. Cooper stated "we were just treating them as if they never occurred, so therefore there was nothing tc log." Cooper indicated, however, that he had never been told by his supervisors not to log unsuccessful tests as an effort to hide the fact that they were having problems in this area. See pages 20 and 21.

When questioned about possible unrecorded water additions as a mechanism to manipulate leak rate tests results, Cooper stated that he never added water

, during a leak rate test that was not accounted for in the computer calcu-l 1ation. See page 34. According to Cooper, if an addition was made and not, entered into the comp ter, it was caused by misconnunication between the operators: "[T]he best I can tell you is that it wasn't done on purpose and it wasn't done with any malicious intent to fool the computer or anything like that. It could only have been a lack of connunication..." See pages 40 t and 41. Cooper indicated that "[t]here were numerous instances when we got fouled up and had to stop a leak rate that we had in progress because we had altered the conditions of the test." Cooper said, it got to the point sometimes, because they were so busy and they were running the tests a couple of times a shift, that they put up 3x5 cards by the reactor coolant drain tank and the makeup tank controls that indicated a leak rate test was in progress (i.e., don't add water or pump down the drain tank). See page 38.

When asked if he was aware of other operators that used unrecorded water additions to insure themselves the margin of getting a good leak rate test

, result, Cooper replied that he knew it did not happen on his shift, but he had the feeling that it was hap >ening on Hartman's shift. This was based

[ upon innuendoes or things that iartman or Bocher might have said (Note:

j Harold Hartman and Raymond Booher were CR0s on Shift "E.") See page 34.

Cooper was then questioned in detail about the effects of hydrogen additions to the makeup tank on leak rate test results. Cooper was read an excerpt of an NRC interview conducted with Joseph Congden in 1980 in which Congdon admitted that hydrogen was added to the makeup tank for the purpose of l

t l affecting leak rate test calculations. According to the report of interview with Congdon (Attachment 3), Congdon stated "the entire shift, himself, Cooper and Adams (Shift Foreman), knew that hydrogen affected the leak rate and that it was his belief it was a group decision to satisfy surveillance requirements." See page 43. Regardless of Congdon's admission Cooper stated that he does not believe that Congdon added hydrogen to affect leak rates. He said he did not know why Congdon made those admissions. See page b6. According to Cooper, "we did believe that hydrogen could affect the outcome of the leak rate, but the methodology, how we did it, or if it would do it consistently, we didn't know and we didn't have any technical basis for understanding what was going on." See page 48.

Cooper stateo during the interview:

"We did, I did, believe that there was some effect when you

' added hydrogen to the make-up tank level indication. I am pretty sure there are occasions when the leak rate was in progress that we added hydrogen and we looked to see if it affected a leak rate result, and lo and behold it did. You know, it was operator curiosity to see if really that was true because we couldn't figure out any reason why that should happen with the way the level transmitter was supposed to work with a dry reference leg, adding that hydrogen would have an effect." See page 48.

Cooper did not consider his actions to be a willful attempt to manipulate test results. Instead, Cooper rationalized his actions in the following manner:

"It' may be splitting hairs. I think the final line is it

wasn't, okay, we are doing a leak rate, let's add hydrogen -

l and maybe we'll get a good leak rate out of it. It is more l like okay, we've got a leak rate in progress, the hydrogen is low, I've got to add hydrogen, lets see how that affects the result. If the result came out good, we accepted it."

See page 49.

In describing other members of his shift, Cooper characterized his Shift Foreman, Charles Adams as: "a real stickler for detail, and, you know, making sure that things were done right. He wanted to make sure that everything was done; he wanted to satisfy management. He wanted to satisfy the procedures; he wanted to satisfy the tech specs. Chuck never led you to believe that cutting corners was okay, or, you know, a little subterfuge here was okay."

See page 57. Cooper said that he was not aware of Mark Phillippe ever manipulating test results. See paje 58.

When questioned further regarding Cooper's earlier statement that he suspected leak rate test manipulation may have occurred on Shift "E," Cooper stated:

"It is a general feeling about the way those guys operated, shoot fron the hip--a lot of it is just strictly, you know, i

personalities of the guys, you know, the rules be damned.

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you know, nobody is going to tell me what to do, I'll do what I want. Both of those individuals are head-strong, unpredictable, and they are going to do whatever makes them feel good at the moment, and if they got a kick out of having us come on shift and relieve them and telling us we got a good leak rate-- nobody else can do it, we got one- .

that kind of gives you the feeling that they did somethin besides just run the test to make that occur." See page 0.

Cooper also was asked about John Blessing, the other CR0 (in training) on Shift "E." Blessing was one of the individual's who previously admitted to the NRC that he added hydrogen to manipulate leak rate test reruits. Cooper said, "I have heard since that he has supposedly admitted to this. John '

didn't fit in with those two guys. He had a lot more integrity." See page 62.

Cooper was asked if he personally brought leak rate test problems to the attention of management. Cooper said that he discussed problems regarding leak rate tests with other CR0s and his supervisors, but did not discuss them with management personnel. When specifically asked if he had conversations regarding leak rate problems with Jim Floyd, Mike Ross, George Kunder, Gary Miller or Jim Seelinger, Cooper responded "no" to all of the above.

When asked if any of these individuals were aware of the problems operators were having with leak rate tests. Cooper responded, "I know that Jim Floyd

! was, the supervisor of operations. He was getting feedback from the shift supervisor. Whatever conversations they were having, he was aware of it."

See page 81.

In closing the interview, Cooper said that to the best of his knowledge, Joe Congdon and Mark Phillippe never added hydrogen to improve the results of

( a leak rate test and he did not believe they would. He also confinned, that i beside his suspicion of what was happening on Hartman and Booher's shift, he was not personally aware of any other operator, senior reactor operator, I shift foreman, shift supervisor or management personnel who purposely manipulated leak rate tests results. Se_e_ page 87.

III. Conclusions Throughout Mr. Cooper's interview he appeared to answer questions in a straightforward manner. Mr. Cooper's testimony confirmed many of the preaccident leak rate surveillance test irregularities that were originally brought to light by fonner THI-2 CR0 H. Hartman. Mr. Cooper's statements were also consistent with D0J's Statement of Facts and evidence developed by O! during its earlier TMI-2 Leak Rate Investigation. During the course of the interview, Mr. Cooper confinned the following items:

1. Cooper had little faith in reactor coolant system leak rate test calculations which were perfonned to show compliance with the Technical Specifications.

2. Leak rate test results were erratic even when tests were run back to back with the same stable plant conditions.

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3. It was common practice to run leak rate tests several times per shift until an acceptable result was obtained. The acceptable tests were retained and the unacceptable tests were thrown away.

4. Cooper felt pressured to obtain an acceptable leak rate test on each shift; however, he did not feel that if he was unable to get an acceptable test by the end of the shift that any adverse action  !

would be taken against him or that his competence as an operator would be called into question.

5. In spite of pressure to obtain satisfactory leak rate test results, i Cooper was never asked or directed by his supervision to manipulate test results.

6. Cooper's first line supervision (Shift Foreman and Shift Supervisor) and he believed middle level management (Supervisor of Operations) were knowledgeable of the difficulties operators were experiencing in obtaining satisfactory test results.

7. Contrary to the comitment contained in the narrative of LER 78-62/17 Cooper's shift was not instructed in the requirements of

, applicable sections of the Technical Specifications or in the requirement to immediately invoke the Technical Specification Action Statement when the associated Limiting Condition for Operation was exceeded. Note: This statement is consistent with the prosecuting attorney's Itafement of Fact read into the record as part of the trial settlement.

! 8. The only instruction Cooper received following the October 18, 1978 i incident, associated with LER 78-62/1T, was to insure that bad leak rate test surveillance sheets were thrown away and not left lying around the control room where the NRC could find them. -

9. Cooper was aware that hydrogen additions to the makeup tank would

. affect makeup tank level indication and thus affect leak rate surveillance test results. However, he felt the effect was not always consistent.

10. Cooper did not understand the technical reason why hydrogen addition j effected makeup tank level indication.

11. Cooper admitted knowingly adding hydrogen to the makeup tank, if hydrogen was low in the operating band, during periods in which leak rate surveillance tests were being run. If the test result came out acceptable. Cooper retained the test as documented evidence of demonstrating confomance with the Technical Specifications.

12. Cooper stated that he never intentionally added water to the makeup tank to effect leak rate test results. If water was added and not included in the calculation, he felt it was because of cperator miscommunication between the operator performing the test and the operator doing the water addition. Note: In some tests Cooper held both positions.

13. Cooper suspected at the time that Shift "E" involving H. Hartman and R. Booher may have been manipulating leak rate test results; however, he had no proof to confirri his suspicions.

14. Other than his suspicions regarding Shift "E," Cooper was not aware of any operator, supervisor or manager who intentionally' manipulated or directed manipulation of leak rate test results.

The only area in which Mr. Cooper's statements are not credible concern his direct involvement in leak rate test manipulation. Cooper admitted knowing hydrogen additions during leak rate tests could (and sometimes did) alter leak rate test results. Cooper also admitted adding hydrogen during leak rate tests and observing makeup tank level indication to see if the hydrogen addition had any effect. Cooper stated that if the test result came out within the allowable Technical Specification acceptance criteria, he accepted the test as valid. Based upon Mr. Congdon's admission on April 10, 1980 that hydrogen was added for the purpose of effecting the leak rate calculation and that this was a group decision (Congdon, Cooper and Adams). Cooper's explanation that he only added hydrogen during a leak rate test if hydrogen was low in the operating band and not for the purpose of altering leak rate test results is not credible. Regardless of his postaccident rationalization, Cooper knowingly affected leak rate tests by the addition of hydrogen to the makeup tank.

Cooper's statement that he never added water to the makeup tank during periods in which leak rate tests were being conducted without including the additions in the leak rate test calculations also does not appear credible.

Cooper's explanation that if such an addition did take place and was not included in the test calculation, it was due to miscomunication between the operators does not appear to be supported by the facts. Between September 30, 1978 and March 24, 1979 Mr. Cooper was involved in 29 leak rate surveillance tests. (8y Mr. Cooper's own admission, he was involved in many more; however, these test records were not retained). Water additions appear to have been made during 14 of these tests. In only one instance, was the water i

addition logged in the CR0 Log and included in the test calculation. The other 13 water additions were neither logged in the CR0 Log nor provided as input to the computer. It does not appear reasonable to assume operator miscomunication occurred during 13 out of 14 tests. In addition, four of the 13 tests records show that Mr. Cooper signed both the CR0 Log and the leak rate surveillance sheet.

In sumary, Mr. Cooper confirmed many of the preaccident leak rate testing irregularities that took place at THI-2. While it is not clear whether Mr. Cooper's statement that he did not intentionally manipulate leak rate test results is true, or whether it is a postaccident rationalization, the staff believes that Mr. Cooper did intentionally manipulate leak rate test I results based upon his knowledge that hydrogen and water additions wculd alter the results and the fact that he made both types of additions during leak rate tests. It is clear from other aspects of his testimony that first line supervision and middle level management at THI-2 were knowledgeable of the difficulties operators were experiencing with leak rate surveillance testing and took r.o action to correct the situation. Mr. Cooper was a relatively junior member of the Operations Department at the time of the accident, and while his actions in many cases were known to be wrong, these actions were apparently comon practice among operators at THI-2.

NOTE: This enclosure discusses information that is maintained in the NRC's Privacy Act System of Records (NRC-16). This enclosure may not be disseminated outside the NRC without cocrdination with NRR and the permission of the EDO. Internal access and distribution should be on a "need to know" basis.

Enclosure 2 Current Performance I. Background 4

On September 28, 1984, an interview was conducted with Mr. Martin Cooper, a Senior Reactor Operator at San Onofre Nuclear Power Station in order to determine Mr. Cooper's understanding of his responsibilities fo.r the safe operation of the plant and his commitment to those procedures and operating principles necessary to carry out those responsibilities. Participating in.

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the interview from the NRC were William Russell, Deputy Director, Division of Human Factors Safety and Leonard Wiens, Senior Examiner, Operator Licensing Branch. Mr. Mike McBride, an attorney representing Mr. Cooper, was also present at the interview. In addition to the interview with Mr. Cooper, interviews were conducted with Mr. Cooper's supervisors on September 26 and 27, 1984. Supervisors interviewed include:

Name Position / Title H. Marsh Operations Supervisor R. L. Brown Shift Supervisor V. Fisher Assistant Plant Manager D. Mette Simulator Supervisor Section II provides a summary of the interviews with Mr. Cooper and the supervisors identified above.Section III provides an overall conclusion regarding Mr. Cooper's current performance.

II. Interview Summary Mr. Cooper appeared to be a very conscientious, dedicated operator. His commitment to operate the plant safely and in accordance with all procedures and regulations appeared to be sincere and complete. He also demonstrated a l thorough knowledge of procedures and technical specifications and the ability 1

to use them. He appeared to be a dynamic forceful supervisor, willing to direct subordinates, accept responsibility for his own actions and get things done on his shift.

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I 111. Conclusion No information was obtained from the interviews with Mr. Cooper .

. . . . . . , . . ..., , whic) could be used as a basis for revocation or modification of Mr. Cooper's Senior Operator license. The contrary was true. .

that Mr. Cooper was an exemplary operator and set an ex'ellent c exanple for his peers. The Senior Operator Upgrade Examination Report used to record the results of Mr. Cooper's interview is included as Attachment 1 to this enclosure, and the list of questions asked of Mr. Cooper is included as Attachment 2. ,

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'. Me $'O UNITED STATES 8 A.,#

o NUCLEAR REGULATORY COMMISSION s -

! wasmmorow, o. c. mss October 15, 1985 k.....

MEMORANDUM FOR: Harold R. Den Director Office of Nuclear Reactor Regulation ,

FROM: William T. Russell, Acting Director ,

Division of Human Factors Safety  ;

SUBJECT:

SUPPLEMENT TO JOINT 01/NRR INVESTIGATION AND EVALUATION OF MARTIN V. COOPER a .

Reference:

1. Memorandum from William T. Russell to Harold R. Denton, dated December 3, 1984

Subject:

Results of Joint O!/NRR

. Investigation and Evaluation of Martin V. Cooper

2. Memorandum from William T. Russell to Harold R. Denton; dated May 30, 1985

Subject:

Results of Joint 01/NRR Investigation and Evaluation of Joseph R. Congdon Th+ purpose of this memorandum is to supplement the results of the joint 01/NRR investigation and evaluation of Mr. Martin V. Cooper, currently a SeniorReactorOperator(SRO)atSanOnofre, Units 2and3. The results of the investigation and evaluation were provided to you in Reference 1.

Since Mr. Cooper was the first operator interviewed as part of the joint 01/NRR investigation, Reference 1 discussed the possibility that during the remaining interviews, additional evidence could be developed regarding Mr. Cooper's preaccident activities at TMI-2 that were not considered in the

! report. Subsequent to our September 28, 1984 interview with Mr. Cooper. -

we have interviewed 14 additional former THI-2 Shift Foremen and Control Room Operators (CR0s) on the subject of preaccident reactor coolant system (RCS) leak rate testing irregularities at TMI-2. Included among these individuals was Mr. Cooper's former shiftmate, Mr. Joseph R. Congdon. The results of Mr. Congdon's investigation and evaluation was provided to you in l Reference 2.

As a result of these interviews, new information about leak rate testing practices and test manipulation was developed. Based upon this new information, NRR revised the technical evaluation of several leak rate tests.

l As a result of our revised technical evaluation and Mr. Congdon's testimony, i it is necessary to supplement the report on Mr. Cooper (Reference 1) in two areas.

First, Mr. Cooper admitted adding hydrogen to the make-up tank (MUT) during leak rate tests; however, he denied that it was done with the intent of manipulating the outcome of the tests. According to Mr. Cooper, if hydrogen pressure was low in the operating band, during periods in which leak rate surveillance tests were being run, he would add hydrogen. If the test results were acceptable, Mr. Cooper would retain the test knowing its results may have been influenced by the addition of hydrogen,

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p,a/r~ ^J w j> y"V .

e i Harold R. Denton October 15, 1985 l

According to the testimony of Mr. Congdon on January 29, 1985, Congdon did .

not consider hydrogen additions during leak rate tests to be a violation of  !

the procedure. Yet, he admitted that ne added hydrogen to the MUT during leak rate tests with the intent of influencing the leak rate test results. '

Mr. Congdon also stated that the other CR0s on his shift, including-Mr. Cooper, were aware that this was being done and that both his Shift Foreman and his Shift Supervisor were also aware that hydrogen was being added during tests for the purpose of manipulating test results.

In Reference 1, i concluded that Mr. Cooper's "postaccident rationalization,"

that he did not intentionally manipulate leak rate test results by the _

addition of hydrogen did not appear credible. Mr. Congdon's testimony

! supports this conclusion, Second, I also concluded in Reference 1, that Mr. Cooper may also have

manipulated test results by the addition of water to the MUT during leak rate 1

tests by not logging the additions in the Control Room Log and not including the amount of water added in the leak rate test calculation. That conclusion was based principally on the results of the technical evaluation which showed unaccounted for water additions may have occurred in 12 leak rate tests involving Mr. Cooper. Based upon the reevaluation of those tests, the evidence is not as convincing.

Enclosure 1 provides a sunenary of the NRR evaluation of leak rate tests

, performed by Mr. Cooper during the period September 30, 1978 through March 28, 1979. The results show that unrecorded water additions may have occurred in only five of these tests; however, many other actions occurred which impact the validity of 21 out of the 30 tests involving Mr. Cooper

( 707.) . These include: accepting tests that were conducted during feed and bleed operations or contained water additions that were not properly ,

accounted for in the leak rate test calculation; conducting tests with unreliable or inaccurate MUT level indication as input to the plant computer; running tests during unstable plant conditions; as well as accepting tests that were conducted while hydrogen was added to the MUT. While most of these action rendered the tests invalid, they did not always produce leak rate tests results that were lower than otherwise would have been the case had these actions not been perfomed.

Both Mr. Cooper and Mr. Congdon deny that they intentionally added water to manipulate the outcome of leak rate test results. Nevertheless, both admitted (1) they ran the test at least one or more times per shift and (2) they had little confidence that the test provided a meaningful measure of actual plant leakage. Based upon their testimony and the testimony of other operators on other shifts, coupled with the technical evaluation, it appears that leak rate tests were often conducted in a frivolous manner, such that tests results were accepted as valid as long as the results were less that the technical specification limit regardless of the evolutions in progress during the test. Because the test was treated as an " administrative requirement" that had to be satisfied every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, little review, if any, was done by CRO's performing the test or the Shift Foreman approving the test.

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- Harold R. Denton October 15, 1985 In sumary, my original conclusion that Mr. Cooper was involved in leak rate test manipulation by the use of hydrogen additions is supported by the testimony of Mr. Congdon; however, my conclusion that Mr. Cooper knowingly manipulated test results by unaccounted for water additions may not be valid.

Rother than intentional test manipulation, it appears that Mr. Cooper and

' others conducted leak rate tests without regard for the precautions and limitations specified in the test procedure. If test results exceeded the limits of the technical specifications, they were discarded. If tests results were below the acceptance criteria, they would be kept with little or no review to assure they were valid tests.

From the testimony of the majority of other CR0s and Shift Foremen interviewed, it is clear that management's standards for procedural compliance were lax and permissive. In my opinion, this was created through negligence on the part of mar,agement. Lack of operator respect for the leak rate test procedure itself, coupled with management's failure to correct leak rate test procedure problems and instill high standards for procedural compliance led to conditions where the leak rate test was conducted in a frivolousmannerwithoutestablishingthepropersteady-stateconditionsfor' the test. In some cases, management s attitude toward this testing motivated operators to manipulate or falsify leak rate test results.

, I continue to believe"that there'is reasonable assurance that Mr. Cooper has and will continue to fulfill the terns and conditions of his current Senior Reactor Operator License. I therefore, continue to recomend that.no enforcement action be taken against Mr. Cooper.

Enclosure 2 provides a comparison of the results of the original leak rate ,

test evaluation, used as a basis for my conclusions in Reference 1, with the the results of the July 30, 1985 NRR final evaluation. Enclosure 3 is a copy of the NRR evaluation.

40  % T- /: 44 William T. Russell, Acting Director Division of Human Factors Safety, NRR l

Enclosures:

As stated

(

cc: B. Hayes K. Christopher l

Enclosure 1 TECHNICAL EVALUATION OF LEAK RATE TESTS PERFORMED BY M. V. COOPER In 1983 and early 1984,~a technical analysis of the leak rate surveillance tests conducted during the last six months of operation of TMI-2 was perfomed by the NRC. This analysis was done as technical support to the Department of Justice (DOJ) in its criminal proceeding against Met-Ed.

During Mr. Cooper's September 28, 1984 interview, he was questioned on the results of this early evaluation. . In 1985 NRR perfomed a reevaluation of that analysis by factoring in additional plant data and information that was learned during interviews with fomer TMI-2 operators, including Mr. Cooper's shiftmate, Mr. Joseph R. Congdon. A discussion of results of this revised evaluation, as it relates to Mr. Cooper, is presented below.

GENERAL In order to demonstrate that reactor coolant system (RCS) leakage did not exceed the limiting conditions for operation. TMI-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-2 Surveillance Procedure 2301-301, "RC System Inventory," was the approved procedure governing the conduct of leak rate tests. The procedure cautioned the operator to avoid the addition and removal of water from the RC

and make-up systems during the test' including make-up or chemical addition to the make-up system or boration/deboration. In addition, the operator was .

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. The procedure also cautioned that power level changes were to be minimized and for the most accurate determination of RCS leak rate, the initial and final conditions of reactor power, RCS temperature, pressure and pressurizer level should be identical.

The vast majority of leak rate tests perfomed at TMI-2 were done by using the plant computer. The computer-generated leak rate surveillance test sheet would be signed by the control room operator (CRO) performing the test and approved by a Senior Reactor Operator (SRO). In most cases, the Shift Foreman approved the tests run on his shift. The test records show that of the 161 leak rate surveillance tests retained by the licensee during the period under investigation, Mr. Cooper was involved in 30 leak rate surveillance tests. During these tests, Mr. Cooper was either the operator perfoming the test or the operator assigned to the control panel. The table below shows a breakdown of NRR's overall conclusions regarding these tests.

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L-__ _. . - - - _ _ - - - - - - _ - _ - _ _ - - . -- - - - - - - - .

, Breakdown of Leak Rate Tests Involving M. V. Cooper 1

Evaluation Category Number of Tests l

Total number of tests on fi1e.................................

Te sts wi th no apparent probl ems . . . . . . . . . . . . . . . . . . . . . . . . . . . .....

. . . . . .9. . 30 1

Unstable or out-of-service makeup tank (MUT) level transmitter..... 7 Water additions to MUT (not included in the calculation)........... 5 Feed and bleed operations (not included in the calculation ........ 4 Hydrogenadditionstothe'MUT.............................)........ . 3 Water or hydrogen addition (unable to differentiate)............... 3 Unidentified leakage greater than the TS limit of I 3 Unstable plant conditions...........................gpm........................... 1 Note: As will be discussed below, three tests (#12E, #29, and #43) fall into two evaluation categories and one test (#36) falls into three evaluation categories.

As can be seen from the table above, only nine of the 30 tests involving Mr. Cooper appear to have been conducted in accordance with the requirements and precautions of the surveillance procedure governing the ccnduct of leak rate tests (SP 2301-3D1). The 21 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.

NORMAL TESTS The nine tests that appear to have been conducted in accordance with the surveillance procedure and yielded test results less than the technical specification limit of I gpm for unidentified leakage are tests:

1. 2 (09/30/76), #5 (10/02/78), #8 (10/05/78), #15 (10/19/78), #26 (10/27/78),

1. 42(12/01/78),#49(12/06/78),#55(12/11/78),and#95(01/15/79).

UNIDENTIFIED LEAKAGE GREATER THAN 1 GPM During a routine inspection of TMI-2 operations on October 18, 1978, an NRC inspector discovered several unsigned and unapproved leak rate tests lying in the control room. These tests indicated unidentified leakage in excess of the technical specification limit of 1 gpm. The inspector also determined that THI-2 had been operating for an extended period of time without entering the action statement of the technical specifications. The incident resulted in the submittal of Licensee Event Report (LER) 78-62/1T on November 1, 1978.

Mr. Cooper's shift (Shift "C") was on watch during the day shift (from 0700 to 1500) on October 18, 1978. Mr. Cooper was assigned as the panel operator and his shiftmate, Mr. Congdon, was assigned surveillance duties. During their watch, four leak rate tests were conducted. The results of three of the tests (#12E, #12D, and #13) indicated unidentified leakage in excess of the technical specification limit. ,

All three tests were later rounded off to 1.0 gpm by the Supervisor of Operations (Mr. Jin Floyd). Tests 12E and 120 were not signed by the operator performing the test or approved by the Shift Foreman (Mr. Chuck Adams). Test f13 was signed by the Shift Foreman, as the operator the test, and approved by the Shift Supervisor (Mr. Brian Mrbler). performing During Mr. Cooper's September 2P,1984 Ol/NRR interview, he stated that the CR0s were not aware of an " authorized rcund-off policy," and refused to sign leak rate tests indicating leakage in excess of the technical specifications.

UNSTABLE PLANT CONDITIONS As stated above, the procedure cautioned the operator to maintain the reactor coolant and make-up systems in a stehdy-state condition during the test by avoiding equipment line-up changes. In order to determine RCS leakage accurately, the initial and final conditions of reactor power, RCS

, temperature, pressure and pressurizer level should be identical. Contrary to the procedure, test #29 (10/29/78) was conducted during a shutdown, while the the plant was not in a steady-state condition. During the test, pressurizer level increased 8.8", Tave increased 1.4*F, and make-up tank level varied 2E6". The large change in MUT level is believed to be caused by a large feed and bleed operation during the test period.

INSTRUMENTATION PROBLEMS At TMI-2 there are two level transmitters (LT-1 and LT-2) that provide MUT level indication. The output of one of the level transmitters drives the MUT 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 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 for leak rate test calculations. When the selector switch was changed to LT-2, the opposite would occur.

Between October 30 and November 6, 1978, operators experienced problems with both level transmitters. At various times during this period, the level transmitters were reading radically different levels in the MUT and both were taken out-of-service for maintenance work and recalibration. During this time period, Mr. Cooper was the panel operator during two tests completed on l

the same shift (mid-shift 2300 to 0700). Test #36 was completed at 2315 on 11/05/78 and test #37 was ccepleted at 0304 on 11/06/78. During these tests,

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. l the LT providing input to the plant computer was reading approximately 15" lower than the LT driving the strip chart recorder in the control room. The LTs were switched between LT-1 and LT-2 several times during the watch, indicating the operators were aware of the instrumentation problems at the time. As will be discussed below, test #36 also contains a hydrogen addition and possible water addition to the MUT during the test period. ,

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 perfomed with the stable level transmitter (LT-2) providing input to the computer during the test. During this period, Mr. Cooper was involved in eight tests. Three were run using stable LT-2 prqviding input to the computer and five were run with the unstable level transmitter. The tests run with LT-2 are: #49(12/06/78),#55(12/11/78),

_ and #62 (12/15/78). The tests run with the unstable LT-1 are: #43 (12/02/78),#44(12/02/78),#48(12/05/78),#51(12/08/78),and#59 (12/12/78).

For tests #43, #44, and #51, 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 #48, the use of LT-1 provided the computer with a change in MUT level of approximately -3.0" instead of an actual value of approximately -2.0" as shown by LT-2. In this case, using LT-1 may have led to a higher value of calculated leakage than would have been the case with stable LT-2. In test #59 the opposite occurred LT-1 provided the computer with a change in MUT level of +0.28", and did not reflect the actual drop in MUT level of approximately -1.0". ,

Thcs,duringtheentireperiodoftimeLT-1wasessentially"out-of-comission, all shifts, including Mr. Cooper's, continued to run leak rate tests (34 out of 50) with LT-1 providing MUT level indication to the computer. In most cases, this action resulted in a meaningless calculation of unidentified leakage that could not demonstrate conformance with the technical specification limit of 1 gpm.

FEED AND BLEED OPERATIONS Four tests contain possible feed and bleed operations that were not taken into account in the leak rate test calculation. These tests are:

1. 6 (10/04/78), 12E (10/18/78), #29 (10/29/78), and #43 (12/02/78).

During test #6, a feed and bleed operation of approximately 160 gallons was performed during the test. Since the amount feed appears to be equal to the amount bled and the entire operation was completed during the test, the overall effect on test results appears negligible.

Test #12E contains a possible feed and bleed operation approximately 20 minutes before the end of the test. In this case, the amount feed appears to

be approximately 40 gallons more than was bled from the system. As discussed above, results of this test exceeded the technical specification limit for unidentified leakage (1.32 gpm). ,

Test #29 contains a large feed and bleed operation of approximately 800 gallons that is not included in the leak rate calculation. This test was also conducted during a period of unstable plant conditions causing large oscillations in MUT and pressurizer levels.

Test #43 contains a feed and bleed operation of approximately 200 gallons during the middle of the test. Approximately 40 more gallons was bled from the system than was added during the test. Because this test was also run using the unstable level transmitter LT-1 providing input to the computer, the net effect on leak rate test results is uncertain.

HYDROGEN ADDITIONS In order to limit the oxygen content in the RCS and to provide an increased net positive suction head for the RCS makeup pumps, a hydrogen overpressure was maintained in the MUT. When hydrogen pressure decreased near the low end of the operating band, the CR0 would add hydrogen to the tank.

Theoretically, the addition of hydrogen should not have affected MUT level; however, because of the configuration and environment of the MUT level detection instrumentation system at TMI-2, water could collect in the low-pressure (dry) reference leg of the level transmitters. Under these conditions, the resultant water slug or " loop seal" could cause a temporary increase in the indicated MUT level when hydrogen pressure was increased in the MUT. 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).

Three tests involving Mr. Cooper include logged hydrogen additions. These are tests: #35(11/05/78),#39(11/09/78),and#120(02/15/79).

Tests #36 was started on Shift "D" and completed by Shift "C." In addition to the logged hydrogen addition approximately 15 minutes into the test, which produced a small effect, the test was started during a 500 gallon water addition. Approximately 150 gallons were added during the test. As discussed above, this test was also run while operators were experiencing obvious MUT level instrumentation problems. The difference in readings between LT-1 and LT-2 is approximately 15". Both the water addition and hydrogen additions were done prior to Mr. Cooper's shift relieving Shift "D."

Test #39 contains a hydrogen addition at the beginning of the test; however, because of the time of the addition, the small effect produced. appears to be insignificant with respect to the final value of the calculated leak rate.

According to the testimony of Mr. Congdon, test #120 involved an experimental addition of hydrogen to determine the its effect on MUT level and leak rate

test results. The Shift Foreman (Mr. Chuck Adams) participated in the experiment. The test was conducted by Mr. Cooper. According to the Control ,

Room Log, hydrogen was added 26 minutes before the end of the test; producing approximately a +2.0" rise in MUT level. At the time of the hydrogen addition, the Shift Foreman wrote: " Pressurized MUT" on the MUT level strip chart recorder. ,

WATER OR HYDROGEN ADDITIONS In' addition to the three logged hydrogen additions, three other tests contain possible hydrogen or water additions. These are tests: #62(12/15/78),#126 (02/19/79)and#130(02/26/79).

Test #62 was conducted during the period LT-1 was unstable. The test used stable LT-2 as input to the computer, thus, during the test, the strip chart

~

recorder shows the output of LT-1. Before and during the test, LT-1 shows regular peak to peak oscillations of apprcximately : 12". There is a large break in the regular pattern approximately halfway through the test. It is not possible to determine if this break was caused by plant oscillations, instrumentation fluctuations or a possible water or hydrogen addition during the test. The Control Room Log does not contain any entries regarding plant evolutions during the test period.

Approximately 17 minutes after the start of test #126 MUT level increases approximately +2.0" (60 gallons) and remains offset throughout the test

-period. Again,'no logged additiens of water or hydrogen are recorded in the Control Room Log. Changes in Tave and pressurizer level do not appear to account for this difference.

Before and after test #130 the slope of MUT level trace is -7.0"/ hour. -

l Shortly after the start of the test, the slope shifts to -4.0"/ hour. The Control Room Log does not record plant evolutions which explain the change.

The change in slope is not consistent with changes in pressurizer level or Tave.

l UNRECORDED WATER. ADDITIONS There are five tests which contain possible water additions that are neither recorded in the Control Room Log nor included in the leak rate test calculation. These tests are: #14 (10/18/78), #18 (10/21/78), #24 (10/26/78), #36 (11/05/78), and #135 (03/02/79).

There are no water additions apparent on the NUT strip chart for Test #14; however, due to changes in pressurizer level and Tave during the test, it appears that approximately 100 gallons of water may have been added during the test. Gross leakage before and after the test is approximately 1.5 gpm.

During the test, gross leakage drops to approximately 1.22 gpm. No water additions are included in the Control Room Log or included in the test calculation.

, 7-There are large changes in MUT level and pressurizer level during Test #18.

Nineteen minutes into the test (1258), there appears to be a 50 gallon water additicn to the MUT. The trace is similar to small (50 to 100 gallons) logged additions of boric acid at 0700, 0730, 0830, 1125, and 1209.

During Test #24, the MUT strip chart shows a possible water addition six minutes after the start of the test (2013). The trace is similar to small (25 gallon)loggedadditionsofboricacidat 1800, 1830, and 2116.

As discussed earlier in this evaluation. Test #36 appears to have been

started prior to the completion of a 500 gallon water addition.

! Approximately 150 gallons of water was added during the test period. This test also contains a logged hydrogen addition and obvious MUT level indication problems.

• The MUT level trace during test #135 exhibits unusual character'istics.

Before and after the test, the MUT level slope is approximately -6.0"/ hour.

Shortly after the start of the test, the slope changes to +4.0"/ hour for the' first half of the test and then returns to the original slope. Based upon changes in pressurizer level and Tave, it appears that approximately 30 to 60 gallons of water may have been added durin0 the test.

SUMMARY

The technical evaluation shows that between September 30, 1978 and March 28, 1979, 21 of the 30 tests (70%) involving Mr. Cooper appear to contain actions that were contrary to the requirements of TM1-2 Technical Specification 3/4.4.6.2 and the precautions, limitations and requirements of Surveillance Procedure 2301-3D1. These actions included: ignoring test results greater .

than the technical specification limit; accepting tests that were conducted dering feed and bleed operations or contained water additions that were not

~

properly accounted for in the leak rate test calculation; conducting tests that used unreliable or inaccurate MUT level indication as input to the plant computer; conducting tests during unstable plant conditions; and accepting tests that were conducted while hydrogen was added to the MUT.

Mr. Cooper and Mr. Congdon have both admitted that they signed and submitted leak rate tests, knowing that the results of these tests may have been favorably influenced by hydrogen additions during the tests. However, both individuals deny that they used any other method, including unaccounted for

! water additions, to manipulate the outcome of leak rate test results. From

! the technical evaluation, it is not possible to prove that these other actions were done with the intent of wrongfully influencing the outcome of tests. There is no clear pattern of test manipulation and in some cases, while the actions challenge the validity of the test, they did not always produce leak rate test results that were lower than would otherwise have been the case. It does appear clear; however, based upon the high number of questionable or invalid tests, that Mr. Cooper accepted test results as valid as long as the results were less than the technical specification limit, regardless of the evolutions in progress during the tests.

l- .

. Enclosure 2

, COMPARISON OF TEST EVALUATION DIFFERENCES FOR M. V. COOPER Overall Evaluation Original Final Number of Tests included in evaluation......................... 29 30 No ma l Te s t s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 9 Questionable Tests............................................. 16 21 Evaluation Category 0f Questionable Tests Code Unstable or Unreliable MUT LT used as input to computer.. LT 0 7 Water addition not included in calculation............... WAN 12 5 Feed and Bleed operation not included in calculation..... F&B 1 4 Water or hydrogen addition (unable to differentiate)..... WorH 0 3 Hydrogen additions to MUT................................ H 4 3 Unidentified leakage greater than TS limit of 1 gpm...... 1GPM 1 3 Unstable plant conditions................................ USPC 2 1

• Note: Original evaluation includes four tests in 2 categories and the Tiiial evaluation includes 3 tests in 2 categories & 1 test in 3 categories.

j Individual Breakdown of Tests By Evaluation Category Test Number Date Original Evaluation Final Evaluation z 0973tT/78 normal Test Normal Test 5 10/02/78 Normal Test Nomal Test 6 10/04/78 Nomal Test F&B 8 10/05/78 Normal Test Normal Test 120 10/18/78 Not Included 1GPM 12E 10/18/78 Not Included 1GPM/Possible F&B 13 10/18/78 1GPM/WAN 1GPM 14 10/18/78 WAN Possible WAN 15 10/19/78 Nomal Test Normal Test -

18 10/21/78 WAN WAN 24 10/26/78 WAN Possible WAN

. 26 10/27/78 Normal Test Nomal Test 29 10/29/78 USPC/WAN USPC/F&B 36 11/05/78 WAN/H WAN/H/LT 37 11/06/78 Nomal Test LT 39 11/09/78 H H 42 12/01/78 USPC Nomal Test 43 12/02/78 F8B/H F&B/LT 44 12/02/78 Nomal Test LT 48 12/05/78 Normal Test LT 49 12/06/78 WAN Normal Test 51 12/08/78 Nomal Test LT 55 12/11/78 Nomal Test Nomal Test 59 12/12/78 WAN LT 62 12/15/78 WAN Possible WorH 95 01/15/79 WAN Normal Test 120 02/15/70 H H 126 02/19/79 Nomal Test WorH 130 02/26/79 WAN WorH 135 03/02/79 WAN Possible WAN l 154 03/24/79 Normal Test Not Included Note: Original evaluation refers to 1983/1984 NRC evaluation of leak rate tests used in December 3,1984 joint 01/hRR investigation and evaluation of Mr. Cooper. Final evaluation refers to 1985 NRR Evaluation dated 07/30/85.

/ g UMTED STATE Enc Msure 6

[ NUCLEAR REGULATORY

$ WASHINGTON, D. C. foast t

May 30,1985

%, .... 1 MEMORANDUM FOR: Harold R. Denton, Director Office of Nuclear Reactor Regulation FROM: William T. Russell, Acting Director Division of Human Factors Safety, NRR

SUBJECT:

RESULTS OF JOINT 01/NRR INVESTIGATION AND EVALUATION OF CRAIG C. FAUST

Reference:

1. Memorandum from S. J. Chilk (SECY) to B. B. Hayes (01) and W. J. Dircks (EDO) dated April 2, 1904,

Subject:

Staff Requirements-Discussion of Pending Investigation-TMI

~

2. Memorandum from H. R. Denton (NRR) to B. B. Nayes (01) dated May 3, 1984 Subject NRR Review of 01 Investi-gation Materials Concerning Hartman Allegations of Falsification of Leak Rate Data at TMI, Unit 2

3. Memorandum from W. T. Russell (DHFS) to H. R. Denton (hRR) 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. Craig C. Faust, currently a Senior Reactor Operator (SRO) at Three Mile Island, Unit 2 assigned to the Training Department, and to provide a recomendation regarding whether his current SEO license should be revoked, modified, or suspended under 10 CFR 55.40 or other enforcement action taken under 10 CFR Part 55.50, due to his involvement in preaccident leak rate testing irregularities at THI-2.

Background

As a 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 OI those matters which required further investigation. The results of NRR's NOTE: This memorandum and Enclosure 1 discusses information which is the subject of an ongoing O! investigation. This memorandum and Enclosure 2 discusses information that is maintained in the NRC's Privacy Act System of Records (NRC-16). This memorandum and i enclosures may not be disseminated outside the NRC without coordi-nation with NRR and the permission of the EDO or the Director. 01.

Internal access and distribution should be on a "need to know" basis.

l w - wy e m ar ,m J&

Harold R. Denton May 30.1985 t

review was provided in Reference 2. The review determined that follow-up investigation by O! and further evaluation by NRR was needed in the case of seven currently licensed operators. C. G. Faust was one of these seven individuals. At a follow-up Comission meeting on May 23, 1984 NRR pro-posed joint OI/NRR investigations and evaluations of these individuals.

Subsequently, NRR issued letters to these individuals under 10 CFR 55.10(b)

' requesting additional information regarding current performance. Based upon the joint investigation into the individuals' past involvement in improper activities at THI-2 and an evaluation on the individuals' subsequent per-formance, NRR would recomend what action, if any, should be taken against the identified operators. As a result of some of the early interviews with these individuals and further technical analysis, Reference 3 recomended that three additional currently licensed operators also be interviewed. NRR

- issued similer letters to these individuals under 10 CFR 55.10(b). Of the ten individuals identified for investigation, seven are currently licensed at Three Mile Island, Unit 2 two are licensed at Waterford 3 and one is licensed at San Onofre 2 and 3.

Past Involvement in THI-2 Leak Rate Testing Irregularities On January 30, 1985, a joint OI/NRR interview of Mr. Craig C. Faust was held

in Harrisburg, Pennsylvania. The interview was conducted in the presence of 1

Mr. Faust's personal attorney. The purpose of the interview was to deter-mine Mr. Faust's role, if any, in improper activities associated with Reactor Coolant System (RCS) leak rate surveillance testing at TMI-2 prior to the accident on March 28, 1979. At the time, Mr. Faust was a licensed Reactor Operator (RO) and served as a Control Room Operator (CRO) on Shift "A." A detailed evaluation of Mr. Faust's interview is included as Enclosure 1 to -

, this memorandum.

The majority of Mr. Faust's responses to questions associated with leak rate surveillance test performance at THI-2 were consistent with statements made to the NRC by other former operators. However, Mr. Faust denied that he personally attempted to influence or manipulate the outcome of leak rate test results by the addition of water and/or hydrogen to the make-up tank (MUT) during the tests. Mr. Faust's testimony appears to be consistent with the technical analysis of leak rate tests in which he was involved.

Mr. Faust also denied that he had personal knowledge of or was aware of other operators intentionally manipulating leak rate surveillance tests. During the interview, Mr. Faust relayed the following information:

1 1. Leak rate tests were routinely run once per shift, plant conditions permitting. At times the tests had to be run several times before a satisfactory result was obtained (i.e., unidentified leakage within the Technical Specification limit of 1 gpm). There were periods of time when he was not able to get a satisfactory leak rate test result by the end of his shift.

2. Only satisfactory leak rate test results were retained. All bad leak rate tests were thrown away. In most cases, Mr. Faust was able to justify why the tests were " invalid." When he was not able to justify 1

Harold R. Denton itay 30,1985  ;

why a particular test was invalid, he would give the test to his Shift Foreman. Note: These actions were contrary to THI-2 Technical Specification 6.10. " Record Retention " which required that records of surveillance actisities required by the Technical Specifications be retained for a period of at least' 5 years. ,

3. Mr. Faust did not log satisfactory or unsatisfactory leak rate tests in the CR0's Log. He considered them to be routine in nature and did not normally log items of a routine nature. Note: This action was contrary  ;

to TMI Administrative Precedure 1012. "ShT T helief and Log Entries,"

which required the test title, number of the test, and the start and completion times of all surveillance tests be logged in the CRO's Log.

4. Mr. Faust's first line supervision (Shift Foreman and Shift Supervisor) were knowledgeable of the difficulties operators were experiencing in obtaining satisfactory test results. These same individuals were aware 1

that invalid test results were being thrown away.

5. Contrary to the commitment contained in the narrative of LER 78-62/1T.

Faust does not recall being given guidance or instruction regarding the proper interpretation of Technical Specification 3.4.6.2, " Reactor Coolant System Operational Leakage." Following this incident, Mr. Faust was not instructed to invoke the Action Statement of the TS when a leak

, rate test result exceeded the TS Limits for unidentified leakage. Note:

l These actions are contrary to TMI-2 TS 3.4.6.2 and the licensee's stated corrective action in LER 78-62/1T of November 1, 1978. ,

6. Although Mr. Faust could recall one discussion with other operators regarding the possible influence of hydrogen additions on leak rate tests, Mr. Faust was not aware whether hydrogen could influence the outcome of the test. He did not personally add hydrogen to affect leak rate test results. He was not aware of other operators adding hydrogen for that purpose.

7. Mr. Faust was aware of methods that could be used by operators to affect the outcome of a leak rate test by either water additions that were not included in the calculations or by the switching of level transmitters for make-up tank (MUT) level indication during the performance of leak rate test. He stated he did not personally use either of these or any other methods to affect the outcome of leak rate tests.

In sumary, Mr. Faust appeared to answer all questions in a straightforward and honest manner and while some of his actions regarding the conduct of leak rate surveillance testing were contrary to the TMI-2 written procedures and Technical Specifications, the technical analysis of leak rate surveillance tests supports a finding that Mr. Faust did not intentionally perform evolutions that would improperly influence the outcome of leak rate tests.

l

\

l e

Harold R. Denton May 30, 1985 Current Performance On January 31, 1985, NRR conducted an interview and oral examination of Mr. Faust, currently a Senior Reactor Operator at THI-2 assigned as an instructor in the Training Department, in order to determine Mr. Faust's understanding of his responsibilities for safe operation of the plant and his.

comitment to the procedures and operating principles necessary to carry out those responsibilities. Interviews were also conducted with Mr. Faust's supervisors on January 30, 1985. Enclosure 2 to this memorandum contains the i

evaluation of Mr. Faust's current performance as well as the Senior Operator Upgrade Examination Report used to record the results of Mr. Faust's inter-view,and a copy of the questions asked Mr. Faust during the interview.

Throughout the interview, Mr. Faust appeared to be a very conscientious and dedicated operator. Although he is an instructor in the Training Department, he showed confidence and appeared to be comfortable discussing shift opera-tions. He was very knowledgeable of the plant and plant procedures, both from a classroom and from an operational aspect. Overall, he appeared to strive to operate safety and in accordance with all applicable procedures.

In summary, no information was obtained from interviews with Mr. Faust which would question his ability to perform the duties of a licensed Senior Reactor Operator at TMI-2. .

Conclusions During the period Mr. Faust was licensed as a Control Room Operator at THI-2 prior to the accident, he admitted he was involved in some activities associated with leak rate testing which were contrary to plant procedures and

. approved Technical Specifications. However, he denies that he was involved in other actions including leak rate test manipulation or falsification or knowledge that such actions were going on around him. The technical eval-untion of leak rate tests involving Mr. Faust tends to support his statements that he was not personally involved in leak rate falsifications. Based upon the consistency of his testimony with subsequent technical analysis and plant records, his statements concerning lack of knowledge of other operators actions to influence leak rate testing is credible.

Harold R. Denton May 30,1985 I believe Mr. Faust does understand his duties and responsibilities for conducting safe operations at TMI-2 and that he is comitted to following the approved procedures and principles necessary to carry-out those resoonsi-bilities. , ,, . .

.. . . . . . ......I believe that'there is

, reasonable assurance that Mr. Faust has and will continue-to fulfill.the. -

terms and conditions of his current Senior Reactor Operator's license. I, therefore, recommend that no enforcement action be taken against Mr. Faust under 10 CFR Part 55 for his past involvement in improper activ.ities associated with preaccident reactor coolant system leak rate surveillance testing at THI-2.

The assignment of Mr. Faust to duties at TMI-1 or other operating reactors is subject to satisfactory completion of the hearing ordered by the Comission (CLI-85-2) into THI-2 leak rate testing.

O. T.iW William T. Russell, Acting Director Divisica of Human Factors Safety Office of Nuclear Reactor Regulation

Enclosures:

As stated cc: 8. Hayes K. Christopher

NOTE: This enclosure discusses information which is the subject of an ongoing OI investigation. This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the ED0 or the Director. 01. Internal access and distribution should be on a "need to know" basis. ,

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

1. Background on January 30, 1985, a joint Office of Investigations (OI)/ Office of Nuclear Reactor Regulation (NRR) interview of Craig C. Faust was held in the law office of Killian & Gephart, Harrisburg, Pennsylvania. The purpose of the interview was to determine Mr. Faust's role, if any, in improper activities associated with Reactor Coolant System (RCS) leak rate surveillance testing-at Three Mile Island, Unit 2 (TMI-2) prior to the accident on March 28, 1979.

Present during the interview representing the NRC were: R. Keith Christopher, Director Office of Investigations, Region I; William T.

Russell, Deputy Director, Division of Human Factors Safety; and Robert Capra, Senior Program Manager, Staff of the Executive Director for Operations.

Representing Mr. Faust at the interview was his personal attorney, Mr. Harry H. Voight of the law firm LeBoeuf Lamb, Leiby and MacRae, Washington, D.C.

A copy of the transcript associated with this interview is provided as Attachment 1 to this enclosure.

Mr. Faust is currently employed by General Public Utilities Nuclear (GPUN) as a Senior Reactor Operator (SRO) assigned to the Training Department and currently holds the position of Instructor IV at TMI-2. Prior to his current employment, Mr. Faust served seven years in the U.S. Navy's Nuclear Power Program. Mr. Faust was hired by Metropolitan Edison Conpany (Met-Ed) upon -

leaving the Navy in December 1973. For the next three years, Mr. Faust served as an Auxiliary Operator (A0) both at TMI-1 and THI-2. In 1976, he

. became a CR0 in training at THI-2 and eventually received his Reactor Operator's (RO) License in October 1977. From this period until he transferred to the Training Department in March 1983, he served as a CR0 at TMI-2. He teceived his Senior Reactor Operator's License in October 1983.

The interview with Mr. Faust concentrated on the period September 30, 1978 through March 28, 1979. During this time period, he served as a Control Room Operator at THI-2 assigned to Shift "A." At that time, Shift "A" consisted of the following licensed individuals:

SHIFT "A"

. Shift Supervisor: Bill Zewe Shift Foreman: Fred Scheimann CRO: Craig Faust CRO: Ed Frederick A summary of the technical analysis of leak rate tests involving Mr. Faust is provided in Section II of this enclosure. A summary of the interview with Mr. Faust is contained in Section III of this enclosure. The summary of

interview in Section III includes citations to the page numbers of the l transcript from which the sumarized information was extracted. Overall conclusions regarding Mr. Faust's involvement in improper activities associated with TMI-2 leak rate surveillance testing.are contained in Section IV of this enclosure. I II. Sumary of the Technical Analysis In late 1983 and early 1984, a technical analysis of the leak rate surveillance tests performed during the last six months of operation of TMI-2 was performed by the NRC. This analysis was done as technical support to the Department of Justice (00J) in its criminal proceeding against Met-Ed. The results of this analysis were used in questioning Mr. Faust during his interview. However, based upon information obtained during the 13 interviews of former CR0's conducted to date, a reanalysis was performed during February and March 1985. The sumary of technical analysis provided in this section relies on the updated 1985 analysis. The major differences between the two analyses, with respect to Mr. Faust will be explained at the end of this section. While the complete 1985 evaluation of leak rate tests at TMI-2 is provided as Attachment 2 to this enclosure, a sumary of the conclusions of the technical analysis regarding tests. involving Mr. Faust is provided below to help the reader understand the basis for.the questions posed to him Juring the interview.

The test records show that of the 161 leak rate surveillance tests retained by the licensee during the period under investigation, Mr. Faust was involved in 20 of the tests. During the 20 tests, he was either the individual who performed the surveillance test or was the operator on watch (i.e., the panel operator) who signed the CRO's Log for the period during which the test was conducted. The table below shows a breakdown of the overall conclusions regarding Mr. Faust's tests.

Breakdown of Leak Rate Tests Involving C. C. Faust Total number of tests on file............................. 20 Tests with no apparent problem............................ 12 Tests involving unstable plant conditions................. 1 Tests involving use of an unstable make-up tank level transmitter as input to the computer.............. 4 Water additions (not included in the calculation)......... 1 Water additions (partially included in the calculation)... 1 Tests indicating unidentified leakage greater than the 1 gprt Technical Specification limit............ 1 Tests involving hydrogen additions......................... O As can be seen from the above table, 12 of the 20 tests involving Mr. Faust appear to have been conducted in accordance with the requirements and precautions of the surveillance procedure governing the conduct of leak rate tests (SP 2301-3D1). The remaining 8 tests, while yielding questionable or perhaps invalid results, do not indicate a pattern of leak rate test manipulation. The basis for this conclusion in presented below.

l

I .

One test, #10 (10/14/78' was performed when the plant was not in a steady state condition. SP 2301-3D1 directs that the test be performed once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady state operation. The procedure also cautions the operator to maintain the RCS and make-up system 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 and the operator should avoid additions or removal of water from the RCS and make-up system during the test. For the most accurate determination of the RCS leak rate, the initial and final conditions of reactor power, RCS temperature, pressure and pressurizer level should be identical. Test #10 was performed during the middle of a reactor start-up following a reactor trip when the plant was not in a steady state condition. One test, #12A (10/16/78),

performed while Mr. Faust was on watch as the panel operator, was an unsigned, unapproved test indicating unidentified leakage of 2.56 gpm which is in excess of the 1.0 gpm Technical Specification limit for unidentified leakage. No water or hydrogen additions were made during this test that would influence the outcome of the test. This test was not filed with the other. surveillance tests maintained by the licensee. Instead, this test was filed with a set of tests that lead up to the submission of LER 78-62/1T on November 1, 1978. The significance of this particular LER is discussed during the interview with Mr. Faust (See Transcript pages 29-35).

During the months of December 1978 and January 1979, one of the two level transmitters that provide make-up tank (MUT) level indication had a very erratic and unreliable output. The output of one of the level transmitters would drive the MUT strip chart recorder in the control room while the other level transmitter would provide MUT level indication to the plant computer.

The plant computer was used to run RCS leak rate surveillance tests at TMI-2.~

A selector switch in the control room allowed the operator to switch level transmitters feeding the strip chart recorder and plant computer. When the selector switch was selected to LT-1, the strip chart recorder would be driven by LT-1 and LT-2 would provide input to the plant computer. When the selector switch was changed to LT-2, the strip chart recorder would be driven by LT-2 and the computer would receive its MUT level indication from LT-1.

Because of the erratic tature of the output of LT-1 during this period, any leak rate test that was performing with the use of LT-1 providing input to the computer must be considered questionable. Of the 54 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. Faust was involved in 5 tests, 4 of which used unstable LT-1 as input to the computer. These tests are: #74 (12/24/78), #83 (01/02/79),

1. 84 (01/04/79) and #85 (01/05/79). Test #74 does not appear to have been affected to a significant degree by the use of LT-1; however, the other three tests do show significant differences between the output of LT-1 and LT-2.

Because of the erratic nature of LT-1, the use of LT-1 as input to the computer would not provide assurance to an operator that actual unidentified reactor coolant system leak rate was less than the Technical Specification limit of 1.0 gpm.

The remaining two tests involve water additions that may net have been properly compensated for in the leak rate test calculations. The

4 surveillance procedure governing leak rate testing cautions the operator to avoid adding or removing water from the reactor coolant system during the period of the test. However, if water must be added or removed, the procedure states that.the amount of the change must be manually inserted into the computer after the plant data has been collected, but prior to the computer performing the actual leak rate computations. l Test #98 (02/02/79) was begun on Shift 8 and completed on Shift A. The test l contains a possible water addition of 110 gallons about 6 minutes before the end of the test. No log entry was made in the CR0's Log and no water l addition was included in the computation. For test #98, it is not clear '

whether or not water was actually added during the test, since the slope of the MUT level rise does not exhibit the " normal" characteristics of a water addition. The evaluation relies on the offset in slope of the MUT level indication between the beginning and the end of the test. Changes in pressurizer level and Tave do not account for the offset. This test is not conclusive from the standpoint of high confidence in the analysis.

Test #149 (03/16/79) involves two water additions during the test. The actual change in MUT level indicates two additions were made of 120 gallons each. The CRO's Log shows one addition of 200 gal. The amount of water included in the computer calculation is 204 gal. Since Mr. Faust was involved in four other tests where water was added and properly accounted

. for, this test appears to be an isolated incident.. It is believed that either Mr. Faust's interpretation of the rise in MUT level indication (30 gal /in) was incorrect or Mr. Faust intended to type "240" into the computer and transposed the numbers and actually typed in "204." Thus, the underrecorded water addition is considered to be a simple human error.

As discussed in the beginning of this section, when Mr. Faust was interviewed in January 1985, he was questioned prior to NRC's updated analysis of the 161 leak rate tests. The earlier analysis included two tests where it appeared hydrogen was added during the test. The 1985 analysis concluded that the spikes were not caused by hydrogen additions but by switching level transmitters between LT-2 and LT-1. The 1985 analysis includes leak rate tests performed during December 1978 and January 1979, which used unstable LT-1 as input to the computer as " questionable." Prior analysis included these types of tests in the " questionable" category only if it appeared water and/or hydrogen additions were made during the tests. Thus, Mr. Faust was not questioned during his interview regarding his knowledge of using the unstable level transmitter as input to the computer. Finally, the unsigned, unapproved leak rate test (#12A) associated with LER 78-62/1T was not included in the package of leak rate tests discussed with Mr. Faust.

In sumary, the overall results of the NRC analysis for D0J used to question Mr. Faust and the revised 1985 analysis support a finding that Mr. Faust did not intentionally manipulated leak rate surveillance tests during the period investigated. Although some of the tests contain elements that call the validity of the results into question, such as the tests performed using LT-1 as input to the computer during its unstable period, there is r.o pattern cf

1 l

. 1 manipulation, as is evident on some other shifts. This is particularly significant during the months of February and March 1979,'when identified leakage was high, resulting in it becoming more difficult to get acceptable test results for unidentified leakage. During this two month peHod, only 16 of the 60 tests retained, that were conducted by all six shifts, appear to have been accomplished in accordance with SP 2301-3D1. Whereas, 7 of the 9 tests run by Mr. Faust meet this criteria.

III. Interview Sumary During the period under investigation September 30, 1978 through March 28, 1979, Mr. Faust indicated that he was primarily assigned to "A". shift. The licensed members of his shift included: Shift Supervisor, W. Zewe; Shift Foreman, F. Scheimann; and Control Room Operators (CR0s) E. Frederick and himself. See page 5.

In describing his shift organization, Mr. Faust stated that one of the two CR0s took the panel or desk. This individual would handle the routine evolutions associated with running the plant as well as directing the duties of the Auxiliary Operators (A0s). The other individual would take the required log readings, handle switching and tagging operations, run certain surveillance tests and take care of most of the paper work requirements of the watch. The CR0s and A0s operated under the direction of the Shift Foreman and the Shift Supervisor. The Shift Foreman was directly responsible for TMI-2, while the Shift Supervisor split his time between TMI-1 and THI-2.

See pages 5-6.

Mr. Faust stated that his shift members all got along and comunicated very -

well with each other. He stated that he had little contact with Mr. Floyd, then Supervisor of Operations for TMI-2. He stated he would talk to Mr. Floyd if Floyd were in the control room; however, he would bring operational problems or questions to his Shift Foreman or Shift Supervisor rather than Mr. Floyd. Mr. Faust stated that he also had little or no contact on a routine basis with other members of on-site management such as Mr. Seelinger (Superintendent of Technical Support prior to December 1978);

Mr. Kunder (Superintendent of Technical Support after December 1978);

Mr. Logan, (Superintendent THI-2); or Mr. Miller (Station Manager). See pages 7-10.

Mr. Faust was provided a copy of THI-2 Surveillance Procedure 2301-3D1,

" Reactor Coolant System Inventory" and a copy of THI-2 Technical Specification (TS) 3.4.6.2, " Reactor Coolant System Operational Leakage."

After reviewing the documents, Mr. Faust stated that the TS required that a leak rate test be run every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. Their shift performed them more frequently. If a bad leak rate test result (i.e., unidentified leakage greater than the TS limits of 1.0 gpm) was received, they would throw the bad test result away. As long as a good result was obtained once during the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, it did not matter how many bad tests were run, they did not have to enter the Action Statement of the TS. See pages 10-12.

1

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i NOTE: Part b of the Action Statement reads as follows: "With any Reactor Coolant System leakage greater than any one of the above limits, excluding PRESSURE BOUNDARY LEAKAGE, reduce the leakage rats within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least HOT STANDBY within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUTDOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />."

In discussing the policy regarding throwing away bad leak rate test results,.

Mr. Faust stated that it may have come from managemen't'(Supervisor of Operations) since that would be the type of thing that they would want handled the same on all shifts. However, Mr. Faust had no first hand knowledge that that was the case. However, he stated the policy was in effect when he started as a CRO. Others were doing it, so he started doing

_ it also. See pages 12-14. '

Mr. Faust stated that as the date of the accident got closer, it was more difficult to get a good leak rate. He stated that the trend of the MUT went from something close to a straight line to where you gradually had a slope.

According to Faust, the increased identified leakage was caused by a leaking Code Safety Yalve at the top of the pressurizer. As identified leakage increased, it would become more difficult to get an acceptable leak rate result within 1.0 gpm for unidentified leakage. Faust said that Plant Engineering would make modifications to the leak rate forms in order to make the leak rate test more accurate. Mr. Faust believed that modifications were made in order to take credit for nonconservatisms in the procedure. When l

identified leakage was not as high, these nonconservatisms did not matter; however, as leak rate tests became harder to run, it became necessary to take credit for them. Mr. Faust specifically remembered one change that was made to the leak rate procedure to account for the difference in densities between water in the reactor coolant system and water in the Reactor Coolant Drain

' Tank (RCDT). See pages 15-17.

Mr. Faust described the way leak rate tests were run on his shift. He stated that leak rate tests were run using the plant computer. When he would start a leak rate test, he would try and inform the other operator that a leak rate test was in progress and not to make any water additions. If a water addition was made and he did not include it in the calculation, he would invalidate the test, throw it away, and run another test. Faust stated that l as the date of the accident approached, they ended up throwing away more leak l rate tests because they were adding water to the reactor coolant system on a l more frequent basis. See pages 18-20.

Mr. Faust was next interviewed regarding an incident that occurred on October 18, 1978.

l NOTE: The incident referred to occurred during a routine i operational inspection of the TMI-2 control room by l an NRC inspector. The inspector discovered that THI-2 l had been operating for a period of two or three days l with several leak rate tests indicating unidentified

l 7

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leakage was in excess of the TS limit. The incident '

resulted in the submittal of Licensee Event Report (LER) 78-62/1T dated November 1, 1978. The narrative' of the LER states, in part, that "This event was caused by misinterpretation of the requirements of the tech-nical specifications. The appropriate personnel will be instructed on the requirements of applicable sections of the T.S. and the requirement to imediately invoke applicable action statements when the provisions of the LCOs are not met." i Mr. Faust was shown a copy of the draft LER with an attached routing sheet with the typewritten names and handwritten initials of control room

_ personnel. Mr. Faust confirmed that the routing sheet was the normal method by which operators were kept informed of events such as this. He did not recall seeing the LER prior to the accident, although his initials were on the routing sheet. Mr. Faust stated that there was a reading file in the control room for operators. Operators documented their reading of the information by initialing the routing sheet. See pages 29-30. Contrary to the statements in the LER Faust did not reca1Tever receiving guidance or any formal instruction with respect to the correct interpretation of the TS following the October 1978 incident. See page 35.

When asked if anything had changed with respect to the way leak rate tests were conducted after the incident, Faust stated that he did not believe so.

He stated that he continued to throw away leak rate tests, if he believed the test was invalid. He would rerun the leak rate test but would not enter the Action Statement of TS. If there was a leak rate test indicating greater -

than 1.0 gpm that he could not invalidate, he would give it to his Shift Foreman. The Shift Foreman would then give direction to the operators such

. as having the A0s go out in the plant and look for leakage. The CR0s specifically would get direction to observe the trend recorder or other instrumentation in the control room in order to discern any changes that might account for the increased leakage. Faust believes the Shift Foreman must have been able to invalidate the tests or "otherwise we would have shut down." See pages 34-35.

When asked if he had ever gone an entire 8 hour9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> shift without getting a valid leak rate test, Faust responded that that had happened. Mr. Faust was asked if he ever had to invalidate a leak rate test because of operator-induced actions. He recalled invalidating tests because of water additions and feed and bleed operations. He said as the accident approached, this happened quite frequently. "It was hard to get a period of time where you could actually run a leak rate and not be affecting it somehow." He said that this happened frequently because of the increased leakage through the code safety valves. He stated that water had to be added frequently to make up for the lost inventory and they had to cycle the pressurizer in order to equalize the boron concentration in the plant that was accumulating in the pressurizer.

See pages 35-37.

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l Mr. Faust was asked if he took any action with respect to the' difficulty this problem was causing. Faust said: .

"I am sure we felt we were going to get to a point where we couldn't meet the limit. We just weren't going to be able 1 to get a leak rate. I think Fred (Shift Foreman) agreed with us. We just will get to a point where you couldn't get l l

one, and end up entering the action statement and shutting '

down." See page 38. i Faust was asked if this possibility was discussed with anyone from their Shift Supervisor on up. Faust responded, "Not that I know of.". When asked if he had ever recomended that the plant be shut down to repair the leakage, Faust said:

"I didn't even make an interpretation like that myself. I don't i

think Ed (Frederick) did either. We just -- you know, at least ,

from my point of view, the way we operated was we operated within the limits that were provided by the tech specs. When you reached those limits, that was cause for shutting down the plant due to a component problem; unless for some reason the site ops director decided that he needed to shut the plant down for an outage, or some scheduled outage." See 39-40.

Faust said that high identified leakage was not the only problem. They were also having problems with the Turbine Generator and the polishing and regeneration systems. See pages 40-41.

In discussing water additions to the MUT, Mr. Faust was asked how he would make a water addition. He described the various sources of water and valve

. line-ups that were possible and that he watched the MUT level indicator to determine how much water was being added using the ratio of 30 gal./in. level change. When asked if he felt that he was able to accurately report how much water was added to the system using this method, Faust stated that he never j had a problem with the amount of water he was adding. See page 42.

l Mr. Faust stated that there were times that water was added to the MUT during leak rate tests. The amount of water added would need to be manually inserted into the computer calculation. If it was not included, it would show up as a negative leak rate. Faust stated that was not the only reason for a negative leak rate. Thus, he would accept a negative leak rate if the numbers looked reasonable. He attributed some of the negative leak rates to instrument tolerances and varying plant conditions. See pages 51-54.

Faust was aske'd how an operator could use water additions to influence the outcome of a leak rate test. Faust stated that you could either add water and not tell the computer or you could switch level transmitters for the MUT level indication. Faust said that since the level indicaters did not always read the same, you could start off the test on the lowest reading transmitter and switch to the higher reading transmitter for the final set of readings.

.g.

This would appear to be a water addition. Faust also said that the water source for demineralized water was outside and that by putting cold water into the MUT, which was around 80*F, the water would expand. Thus, you would get an added " bonus." . Faust said he did not become aware of this latter effect until after the accident. See pages 54-55. However, Mr. Faust stated

, that he had never used any of these methods to assist himself in obtaining a good leak rate test results. See page 55.

Mr. Faust was ssked about Hartman's allegations regarding hydrogen additions influencing the outcome of leak rate tests. Faust stated that he recalled having a discussion with other operators about whether hydrogen could affect the outcome. He did not recall any specifics other than it was.another shift and that the discussion probably took place during watch turnover. See pages 63-64.

Mr. Faust did not believe that hydrogen would affect the outcome of a leak rate test. He was asked if he had ever checked out the theory by adding hydrogen to the MUT and observing MUT level indication on the panel. Faust said that he never carried it out that far. He stated the way he added hydrogen was to tell the A0 to add hydrogen when he was making his rounds, '

but to let him know when it was added. See pages 64-65. Faust recalled that at one time hydrogen could be added from' tee control room; however, for a substantial period of time hydrogen had to be added locally. He could not recall the time period in which hydrogen could be added from the control room. See page 67.

Mr. Faust stated that he did not know if the " hydrogen effect" was comon knowledge. All he recalled was the one discussion during watch turnover. He l did not know if the subject was ever discussed amongst the Shift Foremen or the Shift Supervisors. See pages 65-66.

Faust stated that he probably added hydrogen during leak rat'e tests; however, it was not for the purpose of getting a good leak rate test results. He did >

not recall ever being told by any operators that they were adding hydrogen in order to assist in getting good test results. See pages 65-66.

Next Mr. Faust was shown a copy of the technical analysis of the leak rate tests in which he was involved. He was also shown copies of the lesk rate surveillance test sheets, extracts from the CRO's and Shift Foreman's Logs and copies of the MUT strip charts associated with these leak rate tests. A detailed discussion of the individual leak rate tests involving Mr. Faust took place. It was pointed out to Mr. Faust that the results of his _

testimony was consistent with the technical analysis. Neither his testimony nor the analysis indicated that Mr. Faust was involved in leak rate test manipulation. See pages 68-88.

Next Mr. Faust was shown a comparison of his shift, " Shift A," with the other five shifts. It was pointed out that overall the pattern shows that Shift A was doing things substantially different from other shifts with respect to leak rate tests. He was asked if leak rate testing practices had been

^

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discussed amongst the members of his shift and if they had developed any attitudes toward these tests that might be different from other shifts.

Mr. Faust could not provide any explanation. He was surprised that there was ,

a significant difference in results between leak rate tests performed by different shifts. See pages 38-93.

Mr. Faust could not explain why it appeared that his shif t was able to get good laak rate test results without water and/or hydrogen additions and others were not. He said that there were times when they were not able to get a good test result. In those cases they turned it over to the next shift. f4 hen. asked if he felt pressured to get a goed leak rate test, Faust 4

stated that he did not. "It just means you shut down. We shut,down enough in the past." See pages 93-94.

IV. Conclusions The majority of Mr. Faust's responses to questions associated with leak rate surveillance test problems at THI-2 were consistent with statements mar'e to the NRC by other former operators. Mr. Faust denied that he personally attempted to influence the outcome of leak rate test results by the addition of water and/or hydrogen during the tests. His testimony was consistent with the technical analysis of the leak rate tests in which he was involved.

Mr. Faust also denied that he had personal k.wwledge of or was aware of other operators intentionally manipulating leak rate ar'aillance tests.

During the interview, Mr. Faust relayed the following information:

1. Leak rate tests were routinely run at least once per shift, plant .

conditions permitting. At times the tests had to be run several times before a satisfactory result was obtained (i.e., un1dentified leakage within the Technical Specification limit of.1 gpm). There were periods of time when he was not able to get a satisfactory leak rate test result

by the end of his shift.

2. Only satisfactory leak rate test results were retained. All bad leak rate tests were thrown away. .In most cases, Mr. Faut.t was able to justify why the tests were " invalid." When he was not able to justify why a particular test was invalid, he would give the test to his Shift Foreman. Note: These actions were contrary to TMI-2 Technical Specification 6.10. " Record Retention," which required that records of surveillance activities required by the Technical Specifications be retained for a period of at least 5 years.

3. Mr. Faust did not log satisfactory or unsatisfactory leak rate tests in the CRO's Log. He considered them to be routine in nature and did not normally log items of a routine nature. Note: This action was contrary to TMI Administrative Procedure 1012 7 1ft Relief and Log Entries," which required the test title, number of the test, and the start and completion times of all surveillance tests be logged in the CRO's Log.

s

4. Hr. Faust's first line supervision (Shift Foreman and Shift Supervisor) were knowledgeable of the difficulties operators were experiencing in obtaining satisfactory test results. These same individuals were aware that invalid test result were being thrown away.

5. Contrary to the comitment contained in the narrative of LER 78-62/1T, Faust does not recall being given guidance or instruction regarding the proper interpretation of Technical Specification 3.4.6.2 " Reactor Coolant System Operational Leakage." Following this incident, Mr. Faust was not instructed to invoke the Action Statement of the TS when a leak rate test exceeded the TS Limit for unidentified leakage. Note: These

, actions are contrary to THI-2 TS 3.4.6.2 and to the licensee's stated corrective action in LER 78-62/1T of November 1, 1978.

~

6. Although Mr. Faust could recall one discussion with other operators regarding the possible influence of hydrogen additions on leak rate tests, Mr. Faust was not aware whether a hydrogen addition to the MUT could change the outcome of the test. He did not personally add hydrogen to affect leak rate test results. He was not aware of other operators adding hydrogen for that purpose.

7. Mr. Faust was tware of methods that could be used by operators to affect the outcome of a leak rate test by either water additions that wtre not included in the calculations or by the switching of level transmitters for MUT level indication during the performance of a leak rate test. He stated he did not personally use either of these or other methods to affect the c:;tcome of leak rate tests.

In sumary, Mr. Faust appeared to be :;traightforward and honest during the interview and while some of his actions regarding the conduct of leak rate surveillance testing were contrary to the TMI-2 written procedures and Technical Specification, the technical analysis of leak rate surveillance tests supports a finding that Mr. Faust did not intentionally perform evolutions that would improperly influence the outcome of leak rate tests.

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l NOTE: This enclosure discusses information that is maintained in the NRC's Privacy Act System of Records (NRC-16). This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO. Internal access and distribution should be on a "need to know" basis.

Enclosure 2 I. Background On January 31, 1985, an interview was conducted with Mr. Craig Faust, a Senior Reactor Operator at Three Mile Island Nuclear Station.. Unit 2, in order to determine Mr. Faust's understanding of his responsibilities' for'the' safe operations of the plant and his commitment to those procedures and operating principles necessary to carry out those responsibilities.

Participating in the ' interview from the NRC were William Russel-1, Deputy Director, Division of Human Factors Safety and Leonard Wiens Senior

• Examiner, Operator Licensing Branch. Mr. Smith B. Gephart, and Mr. James Moeller, attorneys representing Mr. Faust, were also present at the interview.

In addition to the interview with Mr. Faust, interviews were conducted with Mr. Faust's supervisors on January 30, 1985. Supervisors interviewed include: -

Name Position / Title Sam Newton Manager Plant Training Ron Maag Supervisor of Licensed Operator Training Section II provides a summary of the interviews with Mr. Faust and the ~

supervisors identified above.Section III provides an overall conclusion regarding Mr. Faust's current performance.

II. Interview Summary Mr. Faust appeared to be a very conscientious, dedicated operater. Although his primary duty was as an instructor at the training center, he showed confidence and appeared to be comfortable discussing shift operations.

He was very knowledgeable of the plant and plant procedures, both from a classroom and an operational aspect. Overall, he appeared to sincerely strive to operate safely and in accordance with all applicable procedures.

III. Conclusion No information was obtained from the interviews with Mr. Faust concerning Mr. Faust's current knowledge or performance which

. 2-would question his ability to perform the duties of a licensed Senior Reactor Operator at TMI-2.

TheSeniorOperatorUpgradeExamination Report used to' record the results of Mr. Faust's interview is included as Ati.achment 1 to this enclosure, and the list of questions asked of Mr. Faust is included as Attachment 2.

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Enclosure 7

[

$ UNITED STATES NUCLEAR REGULATORY CC s wasm=orow, n. c.nossa May 30,1985

-MEMORANDUM FOR: Harold R. Denton, Director ,

Office of Nuclear Reactor Regulation . .

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

SUBJECT:

RESULTS OF JOINT 01/NRR INVESTIGATION AND EVALUATION OF EDWARD R. FREDERICK

Reference:

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

Subject:

Staff Requirements-Discussion of Pending Investigation-

, TMI

2. Memorardum from H. R. Denton (NRR) to B. B. Hayes (01) dated May 3, 1984, Subject NRR Review of 01 Investi-gation Materials Concerning Hartman Allegations of Falsification of Leak Rate Data at THI, Unit 2

3. Memorandum from W. T. Russell (DHFS) to H. R. Denton (NRR) dated January 24, 1985,

Subject:

Follow-up Action on Additional THI-2 Operators The purpose of this memorandum is to document the results of the joint DI/NRR investigation and evaluation of Mr. Edward R. Frederick, currently a Licensed Senior Reactor Operator (SRO) at Three Mile Island, Unit 2 assigned as an Instructor V in the Corporate Training Division, and to provide a recomenda .

tion regarding whether his current SRO license should be revoked, modified, or suspended under'10 CFR 55.40 or other enforcement action taken under

~

10 CFR Part 55.50, due to his involvement in preaccident leak rate testing irregularities at TMI-2.

Background

As a 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 those matters which required further investigation. The results of NRR's NOTE: This memorandum and Enclosure 1 discusses information which is the subject of an ongoing OI investigation. This memorandum and Enclosure 2 discusses information that is maintained in the NRC's Privacy Act system of Records (NRC-16). This metacrandum and enclosures may not be disseminated outside the NRC without coordi-nation with NRR and the permission of the EDO or the Director. 01.

Internal access and distribution shculd be on a "need to know" basis.

I x ' [ W I Wl- z Yf().

Harold R. Denton May 30. 1985 review was provided in Reference 2. The review determined that follow-up investigation by 01 and further evaluation by NRR was needed in the case of seven currently licensed operators. E. R. Frederick was one of these seven individuals. At a follow-up Comission meeting on May 23, 1984, NRR pro-posed joint OI/NRR investigations and evaluations of these individuals.

Subsequently, NRR issued letters to these individuals under 10 CFR 55.10(b) l requesting additional information regarding current performance. Based upon the joint investigation into the individuals' past involvement in improper i activities at THI-2 and an evaluation of the individuals' subs ~equent per-formance, NRR would reconsnend what action, if any, should be taken against -

the identified operators. As a result of some of the early interviews with these individuals and further technical analysis, Reference 3 recomended that three additional currently licensed operators also be interviewed. NRR issued-similar letters to these individuals under 10 CFR 55.10(b). Of the ten individuals identified for investigation, seven are currently licensed at Three Mile Island, Unit 2, two are licensed at Waterford 3 and one is licensed at San Onofre 2 and 3.

Past Involvement in TMI-2 Leak Rate Testing Irregularities On January 30, 1985, a joint Office of Investigations (01)/ Office of Nuclear Regulation (NRR) interview of Edward R. Frederick was held in the law office of Killian & Gephnrt, Harrisburg, Pennsylvania. The interview was conducted in the presence of Mr. Frederick's personal attorneys. The purpose of the interview was to determine Mr. Frederick's role, if any, in improper activitit:s associated with RCS leak rate surveillance testing at TMI-2 prior to the accident on March 28, 1979. At the time, Mr. Frederick was a licensed Reactor Operator (RO) and served as a Control Room Operator (CRO) on Shift .

"A." A detailed evaluation of Mr. Frederick's interview is included as Enclosure 1 to this memorandum.

Mr. Frederick denied that he personally attempted to influence the outcome of leak rate test results by the addition of water and/or hydrogen to the make-up tank (MUT) during the tests. His testimony regarding his lack of persoral involvement in leak rate test manipulation or falsification is consistent with NRR's technical analysis. Mr. Frederick also denied that he had personal knowledge of or was aware of other operators intentionally manipulating leak rate surveillance tests. However, many of Mr. Frederick's responses to questions concerning preaccident reactor coolant system leak rate surveillance testing at THI-2 were inconsistent with the testimony given by the majority of other CRO's interviewed to date. His testimony is also inconsistent in part with the testimony given earlier the same day by Mr. Craig C. Faust, the other CR0 on shift with Mr. Frederick during the six month period under investigation. The majority of conflicts deal with the number of times the test was conducted; the difficulty in obtaining test results that were within the allowable limits of the Technical Specifications; what was done with test results that were unacceptable; and interpretation and compliance with the Technical Specifications and Limiting Condition for Operation associated with RCS leakage. During the interview, Mr. Frederick provided the folicwing information:

Harold R. Denton May 30.1985  ;

1. Although the TMI-2 Technical Specifications required that the RCS leak rate surveillance test be conducted once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, Mr. Frederick recalled that the test was contcted daily, usually on the mid-shift.

If a successful test result was obtained on that watch, Mr. Frederick stated that he would not run it again that day. Note: The majority of operators interviewed have stated that the test was conducted once per shift, plant conditions permitting and provided the plant computer was available. 'Of the 2!

under investigation,! tests involving Mr. Frederick during the period 14 w and 2 on the day-shift. Of the 11 tests performed on the day- or swing-

' shift, 6 times an acceptable test had been conducted earlier in the day.

In one case, 2 acceptable tests had already been conducted.that same day. The difference between Mr. Frederick's recollection.of test frequency and actual test frequency may be attributed to difficulty of recall with the passage of time since the difference between daily testing and testing each shift if plant conditions are stable is not a significant difference in the number of tests performed. This is due to the high frequency of unstable shutdowns, power changes, etc.) plant October between conditions 1978(e.g., start-ups, and March 1979.

2. Mr. Frederick stated that to the best of his recollection, he never threw away any leak rate surveillance test results. He said that all lake rate tests he ran were turned over to the Shift Foreman for his review. He did not know if they were subsequently thrown away or not.

Note: -The majority of operators interviewed have indicated that invalid or unacceptable test results were routinely discarded. In a March 29, 1984 OI interview with Mr. Frederick's Shift Supervisor, Mr. Zewe, stated that the discarding of invalid tests was accepted practice at the time. Mr. Faust also stated in his interview that invalid tests were routinely discarded. Thus, while it is possible that Mr. Frederick did turn all leak rate tests over to his Shift Foreman for review, it does not seem credible that Mr. Frederick would not know that test results showing greater than 1.0 gpm for unidentified leakage were routinely

• thrown away.

3. Mr. Frederick stated that he interpreted Technical Specification 3.4.6.2 as requiring the operator to enter the Action Statement of the Technical Specification whenever they received the results of a leak rate test that exceeded the Limiting Condition for Operation, unless he could explain why the test result was invalid. Note: The m'ajority of operators interviewed including Mr. Faust,TeTieved that they were not required to enter the Action Statement, no matter how many bad leak rate tests were received, as long as they had not exceeded the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> required test interval without obtaining a successful test result.

While Mr. Frederick's interpretation of the requirements of the Technical Specification is correct, there is indication that Mr. Frederick did not comply with this interpretation between October 1978 and March 1979. For example, he testified that he would not be surprised if there were times when they ran a leak rate test on their shift, obtained an unacceptable result and by the end of the shift they i

Harold R. Denton May 30,1985 1

still had not gotten an acceptable result. Since the Action Statement requires that leakage be reduced within acceptable limits wit.hin 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />, had Mr. Frederick followed his interpretation of the requirements of the Technical Specification, as he stated, there would have been periods of time where the plant should have been shut down.

4. Mr. Frederick also testified that he did not recall having difficulty getting leak rate test results within the Technical Specification limits and that if he had any problems he usually knew why. Note: The majority of operators interviewed, including Mr. Faust, indicat H That leak rate test results were difficult to get and that as the date of the accident approached, it became more difficult to get an acceptable test result.

_ Mr. Frederick's statements regarding the difficulty of getting test results also appears to conflict with his later testimony that it would not surprise him if there were several times where they were not able to get an acceptable test result their entire shift.

5. Mr. Frederick testified that he did not log the results of leak rate tests in the CRO's Log for any tests (i.e., good or bad) because items of a routine nature were not required to be logged. Note: Administra-tive Procedure ~1012 requires that the test title, test number, and the start and completion. times of all surveillance tests required by the Technical Specifications be logged in the CRO's Log. Shift "A" was the only shift that did not routinely log satisfactory test results. None of the six shifts logged unacceptable test results.

6. Administrative Procedure 1010 required that problems encountered while ~

performing surveillance testing should be documented on an " Exception and Deficiency List." The list was to be attached to the surveillance test data sheet. Mr. Frederick stated that AP-1010 was not applied to leak rate tests, although he did not know why it had been excluded.

Note: None of the six shifts applied AP-1010 requirements to leak rate surveillance testing.

7. Although he vaguely recalled two other operators (Mr. Hartman and Mr. Booher) complaining about the difficulty of surveillance testing in general, Frederick stated that he personally had no problems running the test. He attributed this to the fact he was very careful in setting up the required initial. conditions for the test. He stated that he questioned all leak rate tests that were received. He stated that he l

could usually predict what it should be. If it wasn't what he expected, he would question it. He examined each test result carefully and if he understood it, then it was alright. Note: These statements do not coincide with the results of the technical analysis which shows that two of his tests were conducted during unstable plant conditions and six tests were performed using the unstable level transmitter (LT-1) as input to the computer for MUT level indication. In four of these tests, there was a significant difference between the output of LT-1 and LT-2.

Had Mr. Frederick reviewed the data carefully, as he testified, he should have seen these discrepancies.

i Harold R. Denton May 30.1985

'I

8. Frederick stated that LER 78-62/1T neither altered his interpretation of the Technical Specification 3.4.6.2 nor did it change the way he performed the test or handled the test results. Frederick stated that he did not have a preaccident recall of the LER.

9. With respect to hydrogen additions, Frederick stated that he was not aware, prior to the accident, that hydrogen additions to the MUT could )

affect MUT level indication and consequently leak rate test results. He  !

did not recall ever discussing the effect with anyone or knowing that

, individuals were adding hydrogen in an attempt to influence the test  !

4 results. Although Frederick was told that Mr. Faust stated he (Faust)  :

j was aware prior to the accident that hydrogen additions were alleged to alter the test results, Mr. Frederick does not recall discu'ssing the subject with Mr. Faust or'any other operator. Mr. Frederick's testimony that he did not add hydrogen to manipulate leak rate test results is consistent with NRR's technical analysis of his leak rate tests.

10. With respect to water additions, Frederick stated that he never inten-tionally added water and not properly included the amount in the leak rate calculation in an attempt to influence the leak rate test results.

He also stated that he was not aware of other operators manipulating tests in this manner. Note: Although, water additions, that were not conpletely accounted for in the test calculation, occurred during three of Mr. Frederick's tests, there are credible reasons why that may have accidently occurred. In addition, the number of tests performed by i

Mr. Frederick, during the high identified leakage period of February and March 1979, where water was added and properly compensated for, supports

! Mr. Frederick's testimony. .

In sumary, the technical analysis supports Mr. Frederick's testimony that he

• did not intentionally add water and/or hydrogen to the MUT during the leak rate tests for the purpose of manipulating the test results. However, other aspects of his testimony dealing with difficulty in obtaining satisfactory test results, the disposition of unsatisfactory results, and his overall knowledge of leak rate testing irregularities raise questions regarding the accuracy of his responses during the interview.

( Current Performance On January 31, 1985, NRR conducted an interview and oral examination of Mr. Frederick, currently a Senior Reactor Operator at THI-2 assigned as to the Corporate Training Division, in order to determine Mr. Frederick's under-standi.ig of his responsibilities for safe operation of the plant and his comitment to the procedures and operating principles necessary to carry out l those responsibilities. Interviews were also conducted with Mr. Frederick's supervisors on January 30 and February 1, 1985. Enclosure 2 to this memoran-dum contains the evaluation of Mr. Frederick's current performance as well as the Senior Operator Upgrade Examination Report used to record the results of Mr. Frederick's interview and a copy of the questions asked to Mr. Frederick during the interview.

l,

~

Harold R. Denton 6- May 30,1985 Throughout the interview, Mr. Frederick appeared to be a sincere, conscien-tious and dedicated operator. Although at times he seemed hesitant in his answers, this hesitation appeared to have been the result of careful consider-ation of each question and iis answer before giving his answer. Although his primary duty involves training, he appeared to be very knowledgeable of shift operations. He generated an overall impression of great sincerity'and as

- someone who naturally accepts complete responsibility for his actions.

t In summary, no information was obtained from the interviews with Mr. Frederick concerning Mr. Frederick's current performance which could be used as a basis for revocation or modification of Mr. Frederick's Senior Reactor Operator's License.

Conclusion During the period Mr. Frederick was licensed as a Control Room Operator at ~

4 THI-2 prior to the accident, he states that he was not involved in nor had knowledge of leak rate testing practices that were contrary to plant proce-dures and approved Technical Specifications. Mr. Frederick also denies that i -

he was involved in leak rate test manipulation or falsification or that he had knowledge that such actions were going on around him. While the technical analysis supports his testimony that he did not intentionally add water and/or hydrogen to t5e MUT during leak rate tests for the purpose of manipulating test results, other aspects of his testimony dealing with difficulty in obtaining satisfactory test results, the disposition of unsatisfactory results, and his overall knowledge of leak rate testing irregularities raise questions regarding the accuracy of some of his responses during the interview.

' . I believe Mr. Frederick does understand his dut'ies and responsibilities for conducting safe operations at THI-2 and that he is committed to following approved procedures and principles neces-l sary to carry-out those responsibilities. . . .

i

Harold R. Denton May 30,1985 In sumary, while I suspect the accuracy of some of Mr. Frederick's state-ments regarding leak rate testing irregularities, I am unable to 1 rove that he lied. I do not believe that he was personally involved in leat rate surveillance test manipulation or falsification.

. I believe that there is reasonable assurance that Mr. Frederick has and will continue to fulfill the terms and conditions of his current Senior Reactor Operator's license. I therefore recomend that no enforcement actions be taken against Mr. Frederick under 10 CFR Part 55 for his involvement associated with preaccident reactor coolant system leak rate surveillance testing at TMI-2.

The assignment of Mr. Frederick to duties at THI-1 or other operating reactors is subject to satisfactory completion of the hearing ordered by the Comission (CLI-85-2) into THI-2 leak rate testing.

4% T-William T. Russell, Acting Director

? =JL Division of Human Factors Safety Office of Nuclear Reactor Regulation

Enclosures:

As stated cc: B. Hayes K. Christopher O

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NOTE: This enclosure discusses information which is the subject of an ongoing OI investigation. This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO or the Director. 01. Internal access and distribution should be on a "need to know" basis.

Enclosure I PAST INVOLVEMENT IN TMI-2 LEAK RATE TESTING IRREGULARITIES I. Background On January 30, 1985, a joint Office of Investigations (b!)/ Office of Nu. clear Reactor Regulation (NRR) interview of Edward R. Frederick was held in the law office of Killian & Gephart, Harrisburg, Pennsylvania. The purpose of the interview was to detemine Mr. Frederick's role, if any, in improper

_ activitiesassociatedwithReactorCoolantSystem(RCS)leakrate 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, Deputy Director, Division of Human Factors Safety; and Robert Capra, Senior Program Manager. Staff of the Executive Director for Operations. Representing Mr. Frederick at the interview were his personal attorneys, Mr. Smith B. Gephart of the law fim Killian &

Gephart, Harrisburg, Pennsylvania and Mr. Harry H. Voight of the law fim LeBoeuf. Lamb, Leiby and MacRae, Washington, D.C.. A copy of the transcript associated with this interview is provided as Attachment I to this enclosure.

Mr. Frederick is currently employed by General Public Utilities Nuclear l

Corporation (GPUN) as an Instructor V in the Corporate Training Division.

Mr. Frederick also holds a Senior Reactor Operator's (SRO) license for THI-2.

+

Mr. Frederick stated that prior to joining Metropolitan Edison Company (Met-Ed) in October 1973, he served as an Electrical Operator in the U. S.

Navy's nuclear submarine program. He was first hired by Met-Ed as Auxiliary Operator (AO) and was promoted to Control Room Operator (CRO) at TMI-2 in 1975. He obtained his Reactor Operator's (RO) license in October 1977. He remained a licensed CR0 at TMI-2 until after the accident in 1979. He was then transferred to the Training Department as an instructor. He was promoted to Supervisor of Non-Licensed Operator Training in 1981. He l received his SRO license in January 1982 and was subsequently promoted to Supervisor of Licensed Operator Training for TMI-2 and then for both TMI-1 l and TMI-2. In July 1984, he was transferred to his present position in the Corporate Training Division.

l The interview with Mr. Frederick concentrated on the period September 30, 1978 through March 28, 1979. During this time period, he served as a CR0 at THI-2 assigned to Shift "A." At that time, Shift "A" consisted of the following licensed individuals:

I 4

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,----,,,,v-------r--e,,ww-,,-,,---n-e---- -,,--r,--emm,--.m--rm--,,,~-_w,-- -

l 2-I SHIFT "A" Shift Supervisor Bill Zewe -

I Shift Foreman Fred Scheimann  ;

CR0 - Craig Faust '

CR0 Ed Frederick l

' A sumary of the technical analysis of the leak rate tests involving Mr. Frederick is provided in Section II of this enclosure. A sumary of the interview with Mr. Frederick is contained in Section !!I of this enclosure.

The sumary of interview includes citations to the page numbers of the transcript from which the summarized information was extracted. Overall conclusions regarding Mr. Frederick's involvement in improper ai:tivities associated with THI-2 leak rate surveillance testing are contained in Section IV of this enclosure, i

II. Sumary of the Technical Analysis In late 1983 and early 1984, a technical analysis of the leak rate surveillance tests performed during the last six months of operation of THI-2 was performed by the NRC. ~This analysis was done as technical support to the Department of Justice (D0J) in its criminal proceeding against Met-Ed. The results of this aralysis were used in questioning Mr. Frederick during his

interview. However, based upon information obtained during the 13 interviews j cf former TMI-2 CRO's conducted 1.o date, a reanalysis was perfctmed during February and Varch 1985. The sumary of technical analysis provided in this section relies on the updated 1985 analysis. The major differences between the two analyses, with respect to Mr. Frederick's tests will be explained at.

i the end of this section. While the complete 1985 evaluation of leak rate l tests at THI-2 is provided as Attachment 2 to this enclosure, a sumary of the conclusions regarding Mr. Frederick is provided here to help the reader understand the basis for the questions posed to him during his interview.

The test records show that of the 161 leak rate surveillance tests retained by the licensee during the period under investigation, Mr. Frederick was involved in 25 of these tests. During the 25 tests, he was either the individual who performed the surveillance test or was the operator on watch (i.e., the panel operator) who signed the CRO's Log for the period during which the test was conducted. The table below shows a breakdown of the overall conclusions regarding Mr. Frederick's tests.

Breakdown of Leak Rate Tests Involving E. R. Frederick Tot al number of te s t s o r, f t 1e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 5 Tests with no apparent problem................................... 13 Tests involving un: table plant conditions........................ 2 Tests involving the use of an unstable make-up tank level transmitter as input to the computer..................... 6 Water addition's that were not included in the calculation........ 2 Water additions that were partially included in the calculation.. 1 Tests indicating unidentified leakage in excess of the TS Limit.. 1 Tests involving hydrogen additions................................ O L . - _ . .. . - - .. . - - _ _ _ - - - - - - .- _ - _ - _ . _ -

l 1

l As can be seen from the table above, 13 of the 25 tests involving Mr. Frederick appear to have been conducted in accordance with the requirements and precautions of the surveillance procedure governing the conduct of leak rate tests (SP 2301-3D1). The remaining 12 tests, while yielding questionable or perhaps invalid results do not indicate a pattern of leak rate test manipulation. The basis for this conclusion is presented below.

Two tests, #10 (10/14/78) and #108 (02/07/79) were performed when the plant was not in a steady state condition. SP 2301-3D1 directs that the test be performed once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady state operation. The procedure also cautions the operator to maintain the RCS and make-up system 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 and the operator should avoid additions or removal of water from i the RCS and make-up system during the test. For the most accurate determination of the RCS leak rate, the initial and final conditions of reactor power, RCS tenq>erature, pressure and pressurizer level should be identical. Test #10 was performed during the middle of reactor start-up following a reactor trip when the plant was not in a steady state condition.

l Test #108 was actually performed by Shift C not Shift A. The test was completed by Shift C eight minutes prior to watch relief and apparently not signed before shift turnover. Mr. Frederick signed the surveillance sheet as

the individual performing the test. This test was also performed during unstable plar.t conditions caused either by changes in power level or by feed and bleed operations. These tests, while in violation of the limits and l precautions of SP 2301-3D1 do not represent the type of operation that would -

l be used to manipulate leak rate test results.

During the months of December 1978 and January 1979, one of the two level transmitters that provide make-up tank (MUT) level indication had a very erratic and unreliable output. The output of one of the level transmitters would drive the MUT strip chart recorder in the control rocm while the other level transmitter would provide MUT 1evel indication to the plant computer.

The plant computer was used to run RCS leak rate surveillance tests at THI-2.

A selector switch in the control room allowed the o>erator to switch level transmitters feeding the strip chart recorder and tie plant computer. When the selector switch was selected to LT-1 the strip chart recorder would be driven by LT-1 and LT-2 would provide input to the plant computer. When the selector switch was changed to LT-2 the strip chart recorder would be driven by LT-2 and the computer would receive its MUT level indication from LT-1.

Because of the erratic nature of the output of LT-1 during this period, any leak rate test that was performed with the use of LT-1 providing input to the computer must be considered questionable. Of the 54 tests conducted by all shifts during this transmitter (LT-2) period providing onlyinput 16 were performed to the with computer the stable d *ing level the test. During this period, Mr. Frederick was involved in 7 tests, 6 of which used unstable LT-1 as input to the computer. These tests are: #64 (12/16/78), #73 (12/23/78), #80 (12/30/78), #83 (01/02/79), #84 (01/04/79) and #85 (01/05/79). Tests #64 and #85 do not appear to have been affected to a I

i

1 significant degree by the use of LT-1; however, the other four tes.ts do show significant differencer between the output of LT-1 and LT-2. Because of the

erratic nature of LT-1, the use of LT-1 as input to the computer would not

. provide assurance to an operator that actual unidentified reactor coolant system leak rate was less than the Technical Specification limit of 1.0 gpm.

Two tests, #12 (10/15/78) and #98 (02/02/79) involve water additions that were not included in the test calculations. Test #12 involved the addition

' of 150 gallons of water near the beginning of the test and a large feed and bleed operation of approximately 600 gallons near the end of the test.

Neither operation is logged in the CR0 Log or included in the test calculation. Mr. Frederick was the individual who had the panel during this l

test, Mr. Germer, a CR0 trainee, was the individual who signed the surveillance sheet as performing the test. Test #98 was begun on Shift B and completed on Shift A. The test contains a possible water addition of 110 gallons about 6 minutes before the end of the test (Shift A). No log entry was made in the CRO's Log and no water addition was included in the 1

computation. For this test it is not clear whether or not water was actually l

added during the test, since the slope of the MUT level rise does not exhibit the " normal" characteristics of a water addition. The evaluation relies on the offset in slope of the MUT level indication between the beginning and end of the test. Changes in pressurizer level and Tave do not account for the offset. Thus, this test is not conclusive from the standpoint of high j confidence in the analysis.

One test, #149 (03/16/79) involves two water additions during the test. The actual change in MUT level indicates two additions were made of 120 gallons -

each. The CRO's Log shows one addition of 200 gallons. The amount of water included in the computer calculation is 204 gallons. Mr. Frederick had the panel during this test and most likely made the water additions while Mr. Faust was the individual who performed the leak rate test. Since Mr. Frederick and Mr. Faust were involved in four other tests during the month of March 1979 where water was added and properly accounted for, this test appears to be an isolated incident. It is believed that either the operators' interpretation of the rise in MUT level indication (30 gal./in.)

was incorrect or the operator (Mr. Faust) intended to type "240" into the computer and transposed the numbers and actually typed in "204." Thus, this test is considered to be a simple human error.

Finally, one test, #12A (10/16/79) performed while Shift A was on watch, was an unsigned, unapproved test indicating unidentified leakage of 2.56 gpm, which is in excess of the 1.0 gpm Technical Specification limit for unidentified leakage. No water or hydrogen additions were made during this test that would influence the outcome of the test. This test was not filed with the other surveillance tests maintained by the licensee. Instead, this test was filed with a set of tests that lead up to the submission of LER 78-62/1T on November 1, 1978. The significance of this particular LER is discussed during the interview with Mr. Frederick (See Transcript pages 58 through 64).

,-,-~,,,e-m,-e--, - - - - .,,-++3------- r m--n mm ~ -~w-

As discussed in the beginning of this section, when Mr. Frederick was inter-viewed in Janaary 1985, he was questioned prior to NRC's updated analysis of the 161 leak rate tests. The earlier analysis included two tests where it appeared hydrogen was added during the test. The 1985 analysis co'ncluded that the spikes were not caused by hydrogen additions but by switching level transmitters between LT-2 and LT-1. The 1985 analysis considers leak rate tests performed during December 1978 and January 1979, which used unstable LT-1 as input to the computer as " questionable." Prior analysis included these types of tests in the " questionable" category only if it appeared that water and/or hydrogen additions were made during the tests. Thus, Mr.

Frederick was not questioned during his interview regarding his knowledge of i

using the unstable level transmitter as input to the computer. Finally, the unsigned, unapproved leak rate test (#12A) associated with LER 78-62/1T was not included in the package of leak rate tests discussed with Mr. Frederick.

~

In sumary, the overall results of the NRC analysis for D0J used to question

, Mr. Frederick and the revised 1985 analysis support a finding that Mr. Frederick did not intentionally manipulate leak rate surveillance tests by the addition of water and/or hydrogen to the MUT during the period investi-gated. Although some of the tests contain elements that call the validity of the results into question, such as the tests performed using LT-1 as input to the computer during its unstable period, there is no pattern of manipulation, as is evident on some of the other shifts. This is particularly significant during the months of February and March 1979, when identified leakage was high, resulting in it becoming more difficult to get acceptable test results for unidentified leakage. During this two month period, only 17 of the 60 tests retained, that were conducted by all six shifts, appear to have been 4 properly accomplished in accordance with SP 2301-3D1. Mr. Frederick was ,

involved in eight of the 17 satisfactory tests.

III. Interview Sumary During the period under investigation, September 30, 1978 through March 28, 1979. Mr. Frederick indicated that he was primarily assigned to "A" Shift.

The licensed members of his shift included: Shift Supervisor, Bill Zewe; Shift Foreman, Fred Scheimann; and Control Room Operators (CR0s) Ed Frederick and Craig Faust. See page 4.

As a CRO, Frederick stated that his job was to manipulate the reactor controls and maintain records of the shift operations. He reported directly to the Shift Foreman. They were in contact throughout the shift. The Shift Supervisor would supervise the "A" Shift on Unit 1 as well, thus, the Shift Supervisor would split his time between the two plants. Consequently, Frederick would see Zewe less often. See page 5.

l

l Frederick stated that he did not have routine contact with the Supervisor of Operations at the time, J. Floyd. Mr. Floyd would come into the control room on day shifts; however, he did not recall discussing RCS leak rate-surveillance testing with Floyd. His principal contact with the Plant Superintendent J. Logan, was in a training capacity. Mr. Logan was trying to get a license on TMI-2, so Frederick had given him some system checkouts and showed him around the plant a few times. He did not recall discussing leak rate testing with Logan. Mr. Frederick stated that his contact with the Station Manager, G. Miller was even more limited. He said he seldom talked to Miller. See pages 6-7.

Mr. Frederick was asked to review a copy of THI-2 Technical Specification 3.4.6.2 " Reactor Coolant System Operational Leakage," and a copy of THI-2 Surveillance Procedure 2301-3D1, " Reactor Coolant System Inventory." After.

reviewing the documents. Frederick stated that the test was required to be run at least once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. That was the minimum number of times. He did recall that the test was conducted more often. He stated that he thought it was done daily and not once per shift. He believed if it was run succenfully once per day that was good enough. See page 8.

Frederick stated that when he ran a leak rate test, he would give the results to the Shift Foreman whether they were acceptable or unacceptable. Then the Shift Foreman would discuss with the CR0s what action was required based upon the results of the test. See page 9.

j With respect to follow-up actions, Frederick said that in certain cases they would start looking for the source of the leakage if the results were in

, excess of the Technical Specification limit. It was usually the Auxiliary .

Operators (A0s) that would do that. In addition, the A0s may have been able to readily identify something that they had changed in the plant that changed

, the leak rate. Frederick stated that when a test result exceeded the limits specified in the Technical Specifications, he considered that they were required to enter the Action Statement of Technical Specification 3.4.6.2 provided the test was valid. See page 9.

, NOTE: Part b of the Action Statement reads as follows: "With any Reactor Coolant System leakage greater than any one of the above limits, excluding PRESSURE BOUNDARY LEAXAGE, reduce the leakage rate within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least HOT $1ANDBY within the r. ext 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUTDOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />."

NOTE: During an interview with Mr. Craig Faust, earlier that day, Mr. Faust stated that the Technical Specifications required the test to be run once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> but they ran them more frequently. If a bad leak rate test result (i.e.,

unidentified leakage greater than the TS limits of 1.0 gpm) was received, they would throw the bac test away. As long as a good result was obtained once during the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, it did not matter how many bad tests were run, they did net have to enter the Action Statement of the TS.

h Mr. Frederick reiterated that he turned in all bad leak rate tests to his Shift Foreman. He was not aware whether the Shift Foreman eventually threw them away. He stated that they could have been. He did not personally recall ever throwing away test results. If it was bad, he would discuss it with the Shift Foreman and then would run another test. He stated that he did not recall Faust throwing tests away. He stated, "We usually did things pretty much the same way." See page 11.

Mr. Frederick also recalled that he did not have difficulty getting acceptable leak rate test results. Frederick said the tests.he had problem.s with, he was usually able to find a reason why it was 'iiivalid or why th.e 1 number was not what he expected it to be. He stated he could not recall periods where he would have to run several tests in a row befoFhe could finally get a good one. See page 11.

At this point in the interview, it was pointed out to Mr. Frederick that his testimony did not appear to match the testimony given earlier that day by the other CR0 on his shift. Mr. Faust. It was noted that there were only two CR0s on their shift and they were both in the control room at the same time every shift, yet from the differences in testimony between Mr. Faust and Mr. Frederick one would conclude that they must have been on different shifts. Three of these differences were discussed with Mr. Frederick. See page 12.

, First, Faust's testimony was consistent with the testimony of most operators i regarding the frequency of running leak rate tests. According to Mr. Faust

! leak rate tests were perfomed normally every shift, subject to plant conditions and the availability of the plant computer. Frederick stated that Mr. Froferick responded that leak rate -

tests were done only once tests were done on the mid-shift 2300 per day (. to 0700). If it was done on that shift, he did not recall perfoming the test again that day. If it was not performed on the mid-shift it would be done during the day shift (0700-1500).

See pages 12-13.

NOTE: Since only good leak rate test results were retained by the licensee, the actual frequency that tests were run is not known. However based upon the 161 tests that were retained 71 (44%),were done on the mid-shift, 37 (23%) were done on the day shift, and 53 (33%) were performed on the swing-shift (1500-2300). The record also shows that 29% of the time more than one good leak rate test exists for the same day. Approximately half (50%) of the time only one good leak rate test exists

for tne same day and for 21% of the time, no leak rate test exists for that day, excluding periods when the plant was in Mode 5 (i.e., cold shutdown).

Of the 25 tests involving Mr. Frederick, 14 were done on the mid-shift, 9 on the swing-shift and 2 on the dcy-shift. Of the 11 tests performed on either the swing or day shifts, 6 times an acceptable leak rate test I

I

. 1 had already been conducted earlier in the day. In one case where Mr. Frederick signed the surveillance sheet as performing the test, 2 acceptable leak rate tests had already been conducted that day. .

Second, Mr. Faust test 4fied that bad test results were thrown away.

Mr. Faust's testimony again is consistent with the vast majority of other operators' testimony. Faust stated that if he could not determine why a test was invalid, then he would turn it in to the Shift Foreman. Mr. Frederick, on the other hand, stated.that he never threw out a bad or invalid leak rate test. Frederick responded by stating: "Well, the details of the paper flow might just not be there. I don't know. I would leave them on his desk, ".he Foreman's desk, to look at, or I would hand them to him personally and t. en we would discuss what to do with them. Maybe Craig (Faust) didn't do it that

, way. Maybe he made the decisions on his own." Frederick continued by saying that if they were being thrown away, he either did not count it as signifi '

cant and didn't remember it, or he was not aware they were being thrown away.

He did not recall either himself throwing any test results or he did not recall seeing other people throw them away. He said he is aware now that it was comon practice, but he does not believe he was aware of it then. See pages 13-15.

Third Faust stated that leak rate test results were hard to get, especially as the date of the accident approached. Frederick stated they were not hard to get. Frederick responded by saying that maybe he defined "hard to get" diffarently. "If the test didn't come out, I didn't consider that a difficulty or a problem to get upset about. I would just either run another

, one or just not run anymore. It was not a difficulty. It was a routine thing." Frederick was then asked if he could recall having to run one test .

after another and still not have a good leak rate test result by the end of his shift. Frederick stated that he did not recall, but it would not surprise him if that was the case several times. See pages 16-17.

Frederick said that he did not concern himself much with leak rates. He said that Faust had gotten into the habit of putting a leak rate into the computer whenever they came into the control room to relieve the shift. He said that 1

if that one came out okay, that was all they would do for the night or during the shift. He said that he had gotten out of the habit of running the tests i because of Faust's routine. He said he would only run a test if it was his 4

turn to take the readings and Faust had not already started a test. See pages 17-18.

l NOTE: The routine described by Frederick appears to con-tradict his earlier statements that he only recalled the test being run once per day on the mid-shift.

! In addition, Mr. Frederick and Mr. Faust were involved j in the performance of 19 tests together. Mr. Frederick signed the surveillance test sheet as the individual performing the test 11 of the 19 times. This fact appears to conflict with Mr. Frederick's testimony that

! he had getten out of the habit of running leak rate tests because of Faust's routine.

, - - - - - - . _ - , . . , . . , , . _ _ _ _ - - , . - - = ,,--n. - - - -. - . - . . _ , , . - - - . . , - - - - ~ ~ - . - - - - ~ - - - - - ~ - ~ + - - - - - - - - - - - - - -

! l Frederick was next questioned about the requirement .a log all leak rate tests in the CR0's Log. He was shown a copy of Administrative Procedure 1012. " Shift Relief and Log Entries." Paragraph 3.3.17 states that the l operator shall " Record title and number of the test perfomed, and the start and completion times or time of suspension of the test. The performance of  :

all periodic tests and inspections required by the Technical Specifications shall be recorded." Frederick stated that he did not log any of the data associated with leak rate tests. He considered this test routine and did not log evolutions of a routine nature. Frederick believed that another procedure AP-1001 stated that items of routine nature did not need to be logged. A copy of AP-1001 was not available to verify his claim. g pages 19-20. ,

NOTE: None of the six shifts logged all of the data required by AP-1012 in the CR0's Log; however, all other shifts, except Shift A routinely logged the completion time and the results of " good" leak rate tests. Leak rate tests that did not meet the acceptance criteria were not logged.

1 Shift A did not log any leak rate test results, good or bad.

Mr. Frederick was also shown a copy of Administrative Procedure 1010 Technical Specification Surveillance Program." It was pointed out to Mr. Frederick that Section 6.5 of the procedure required that problems encountered while perfoming surveillance testing shall be recorded on an

" Exception and Deficiency List" and that this list, when required, was to be attached to the surveillance test data sheets. Mr. Frederick stated that this procedure was not applied to leak rate tests. He does not see how it could have been excluded, however, except by practice. He said that if .

someone would have brought it to his attention at the time, he would have filled out the required form, h pages 21-23.

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Next. Mr. Frederick described how he perfomed a leak ratt test. He stated that the test was done completely by computer. You had to establish the initial conditions for the test such as steady state, no power changes, etc.

Once you established the initial conditions you just typed the right code into the computer and it would collect the data at the beginning of the test and one hour later at the end of the test. He said that it was their practice to infom the other CR0 when the test was in progress so that they could maintain steady state conditions in the plant so that the test would be as valid and as accurate as they could make it. See pages 24-25.

Mr. Frederick was asked if he ever came up with an invalid test because of an operator-induced' change. He stated that that did occur. Usually when it l happened it was because of a water inventory change that was not accounted for in the calculation. He said if he ran the test, he would make a notation as to why he thought it was invalid, or signed it, and gave it to the Shift Foreman and explained what happened. Again, he rtated that he did not know if these tests were thrown out. He suspected that if they were invalid and he could prove it to the Shift Foreman then they were thrown away. Frederick believes that these invalid tests were discussed on several occasions with the Shift Supervisor, Bill Zewe. See pages 25-27.

5

When asked if he had ever had a discussion with his Shift Foreman or his Shift Supervisor regarding how these invalid tests should be handled, he

. stated that he could not recall his Shift Foreman telling him that-the way he was handling them wasn't the way he wanted h'..:. to do it. Thus Frederick believes that his Shift Foreman must have approved of the way he was doing it. See page 27.

Frederick was asked why Faust recalled throwing away tests and he did not.

Frederick stated "It just may be that when Fred (Scheimann) talked with

- Craig (Faust) about invalid leak rates, it was Craig that turned around and threw thim in the wastebasket rather than Fred." See page 27.

When Frederick got a bad leak rate test result, he stated that he could usually toll why. He said that he doesn't know why he did not have as much.

trouble with the test, as apparently others did. He recalled that he spent a lot of time trying to estabitsh initial conditions for the test before he would start it. He believes that that may be one reason why he had better results than others. He stated that he had vague memories about one or two He said operators that formerwho CR0'scomplained H. Hartmanabout surveillance and R. testing)in Booher (Shift general.

F were the individuals .

that he recalled. He remembered them because Shift F relieved their shift quite often. Frederick stated that he did not recall either of them ever mentioning that they were having problems to the point where they would have to do things to influence the outcome of the test. See pages 30-31.

When Frederick was asked if he believed the information that he received from the computer with respect to the accuracy of the leak rate test, Frederick stated that he questioned all the results that were received. He felt that the test tolerance was to limited for the accuracy of the instruments

• involved. He claimed that when he ran a leak rate test, he could usually predict what it should be. If it wasn't what he expected, he would question it. He said that he examined each one carefully and if he understood it, then it was alright. See page 32.

NOTE: As stated in the Sumary of Technical Analysis, Mr. Frederick was not questioned regarding his know-ledge of the unstable MUT level transmitter (LT-1).

However, based upon Mr. Frederick's claim that he examined each leak rate test carefully and questioned any results that were not what he expected, it is hard to understand how 8 of his 25 tests involved either unstable plant conditions (2) or the use of unstable LT-1 as input to the computer (6).

Mr. Frederick confirmed that his understanding of Technical Specification 3.4.6.2 was that if he ran a leak rate test and the results came out greater than one gpm for unidentified leakage, he would enter the Action Statement of the Technical Specification, provided he believed the test was valid. He stated that he would run another leak rate test imediately to confirm the first test. See pages 35-36. Frederick was asked if he had ever run a test n em oei sus-

~

and the results were greater than the Technical Specification limit and at the er.d of four hours he still had not gotten a leak rate test result that was within the acceptance criteria. Mr. Frederick stated that he could not recall such a situation. It was pointed out to Mr. Frederick, th'at P . Faust had testified earlier that at times their shift had gone through an entire shift without getting a leak rate test result within the limits of the Technical Specifications. See page 37.

In discussing the surveillance frequency and the requirements of the Action Statement, Mr. Frederick stated that the Technical Specifications required that the test be run at least every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. However, he believes the test was run once a day. He stated that "everyt seems to be saying that they did them every shift, therefore, they had , get a correct one every shift.

Perhaps I avoided all of that because I only did them when the surveillance either called for it or someone made a special request." See pages 37-41.-

Mr. Frederick was then shown a document which showed graphically, when leak rate tests were run. The document showed that on several occasions, Shift A did run leak rate tests on the same day that another shift had gotten an acceptable leak rate test earlier in the day. Mr. Frederick agreed that it appeared tests were run more than once a day. See page 43.

Frederick was asked if he had ever gotten into a discussion with Mr. Faust regarding the interpretation of Technical Specification 3.4.6.2. Frederick did not recall any specific discussions but that was one of the topics that he enjoyed talking about to everybody. He stated that it's a comon problem in the industry to try and get a single interpretation from every Technical Specification for all the At THI-2 the Technical Specifications were as ope. n topeople that areas interpretation using it.

anywhere else. See 48-49. He also could not recall any specific conversations with hts' pages shift ,

Foreman regarding his interpretation of the Technical Specification. He believes that because of dt?ferences in interpretation, he developed his routine of performing the test, discussing it with his Shift Foreman and allowing the Foreman to make a decision. Frederick stated that he could make a suggestion and interpret the data for the Shift Foreman, but unless Frederick vehemently disagreed with him or his decision on the action necessary, it was up to the Foreman. See pages 49-50.

In describing how he would review leak rate test results Frederick said that he would look at many things. He stated that if something occurred which changed the steady state condition, he would imediately suspect the results of the tett whether it came out less than one or greater than one. Frederick did not consider it difficult to maintain steady state conditions on the back shifts, with the exception of feedwater oscillations that he stated were caused by the Integrated Control System (ICS) tolerances, g pages 50-51.

Occasionally, Frederick stated, he would get negative numbers. He said this could happen if the unidentified leakage was close to zero, just due to instrument tolerances. He stated that if something happened to change identified leakage and you were not aware of it, that could also caure a negative leak rate. See page 51.

i Frederick stated that if he found out that water was added during a leak rate test, he would normally not include the amount of water added in the calculation. Instead, he would just start a new test. He stated.that even with this type of situation, he still turned in the invalid test to his Foreman. He did not recall throwing any of these tests away. See pages 52-54.

It was pointed out to Mr. Frederick that most tests conducted after mid-February 1979, contained water additions during the test, including tests performed by Shift-A. Frederick stated that was true because they changed their mode of operation because of the suspected leakage through one of the code safety valves on the top of the pressurizer. Frederick stated that they had,to add a lot of water to make-up for lost inventory. See pages 52-53.

Frederick was then shown a copy of LER 78-62/17. Frederick indicated that he had seen it several times before; however, the first time he was shown the document after the accident, he could not recall seeing it prior to the accident. Because de did not recall seeing it prior to the accident,

! although he had initialed the review sheet, he stated that the LER had no impact on the way he performed leak rate tests. See pages 58-59.

i NOTE: LER 78-62/1T dated November 1, 1978, dealt with an incident

involving leak rate tests and the " misinterpretation" of i the requirements of the Technical Specification 3.4.6.2 (i.e., the requirement to enter the Action Statement when a leak rate test exceeds the acceptance criteria, regardless 1

if the test was performed more frequently that the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> requirement levied by the Technical Specification). ,

Frederick stated that since he was interpreting the Technical Specification t correctly at the time of the incident, the LER did not alter his performance of leak rate tests. He stated, at that time, he believed that if you performed a leak rate test and the results were greater than the one gpm limit, you were bound by the results, unless the test was invalid for some reason. He stated that, "if you believe the result was greater than one, that was cause for some alarm. If you really believed it, you had to act upon it." See pages 61-63.

• In discussing hydrogen additions Frederick stated that prior to the accident, he was not aware that hydrogen could affect MUT 1evel and consequently leak rate test results. According to Frederick, he does not think that he and Faust discussed the hydrogen effect. He stated that after the accident, when he heard about the Hartman allegations, he spent some time investigating whether or not he thought the effect was real. Frederick concluded that it was not. He said that he examined the prints and diagrams of the MUT and examined the effect of hydrogen additions on the MUT strip charts. It did nct appear to Frederick that hydrogen additions would produce any type of consistent result. Frederick was informed that Faust testified earlier in the day that Faust was aware that hydrogen additions were alleged to be capable of influencing leak rate test results and that he had a discussion i

I_ -

with other operators about it prior to the accident. Frederick reiterated that he and Faust did not discuss it amongst themselves. He continued that he was not aware that hydrogen could be used to alter leak rate test results.

He did not use hydrogen for the purpose of affecting leak rate tests and he did not recall ever entering into any discussions with other operators or supervisors as to the potential impact hydrogen could possibly have on leak rate test results. He said that it may have been possible that he talked with someone about it; however, he does not recall. See pages 68-75.

In discussing water additions Frederick stated that. water was routinely .

added to change boron concentration or to make-up for lost inventory. ~

1 Demineralized (DI) water could be added or else borated water could be added

, from the Boric Acid Mix Tank (BAMT), or the Reactor Coolant Bleed Tanks (RCBTs). Water would be pumped into the make-up tank and then transferred into the RCS via the make-up pumps. Frederick stated that when adding water,

! he would use the totalizer on the batch controller to know hcw much water he added. Although, if he were adding water from the Boric Acid Mix Tank he could also use the stroke counter on the BAMT pumps, since they were positive

. displacement pumps. See pages 74-77.

When asked if he ever used the MUT strip chart to determino how much water was added, he said that he did not. He said that since water was being transferred out of the MUT at the same time water was being added, you would not get an accurate answer unless you stopped the make-up pumps. See pages 77-76.

In adding water, Frederick stated that it was'possible to control or throttle the rate of flow using MU-V-9 in the line going to the MUT. Frederick thought that it would be unusual to throttle MU-V-9 when adding water from ,

the RCBT or when adding DI water. He said that you may want to add water in 4

smaller batches, but he couldn't think of any reason to go to an intermediate position on MU-V-9. See page 80.

Frederick stated that the batch controller contained a current batch counter, a totalizer and an integrator. If he wanted to add 600 gallons in 200 gallen batches, he would set the maximum batch to 600 and the current batch to 200.

The water would start being added until the counter reached 200, at which time the water addition would automatically stop. The counter would then show that 200 gallons of the 600 gallons had been added. Frederick believed that you would have to manually open and close MU-V-9 after each batch. See page 80.

Frederick believed that all water additions were logged in the CR0 Log. He stated that he was familiar with Hartman's allegations that water was added and not recorded or underrecorded during leak rate tests. However, Frederick stated that he did not recall anyone telling him that they did it. He stated he had no knowledge at that time that that practice was being done. He stated that if he personally failed to record a water addition it was a mistake. He did not do so with the intent of trying to change the leak rate l

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i result. Frederick also stated that he never underrecorded a water addition for the samc purpose. See pages 81-83.

The staff's overall co.pclusions regarding the individual leak rate tests involving Frederick were reviewed with him. It was pointed out that there 1

were relatively few instances where water was either added and not included in the calculation or the amount included in the calculation was not as large as the apparent amount ad(ed from looking at the MUT strip chart. The technical analysis supports Mr. Frederick's testimony that he does not appear to have been involved in the addition of either hydrogen or water to the MUT l

in an attempt to influence leak rate tests. See pages 84-98.

+

In explaining why he may have had better success than others, he stated that it seemed that if you set up the test right and took your time about getting the plant oscillations that were going on out of the way, it'seemed to work

! out. In addition, Frederick believes that he had a good grasp of integrated plant response. That was one of the reasons he said he was picked as an instructor. See page 103-106.

IV. Conclusions Mr. Frederick denied that he personally attempted to influence the outcome of leak rate test results by the addition of water and/or hydrogen to the MUT during the tests. His testimony regarding his lack of personal involvement

in leak rate test manipulation or falsification is consistent with NRR's 4

technical analysis. Mr. Frederick also denied that he had personal knowledge of or was aware of other operators as intentionally manipulating leak rate surveillance tests. However, many of Mr. Frederick's responses to questions-concerning preaccident reactor coolant system leak rate surveillance testing at THI-2 were inconsistent with the testimony given by the majority of other

. . CRO's interviewed to date. His testimony is also inconsistent in part with the testimony given earlier the same day by Mr. Faust, the other CR0 on shift with Mr. Frederick during the six month period under investigation. The majority of conflicts deal with: the number of times the test was conducted; the difficulty in obtaining test results that were within the allowable limits of the Technical Specifications; what was done with test results that  !

were unacceptable; and interpretation and compliance with the Technical Specifications and Limiting Condition for Operation associated with RCS leakage.

During the interview, Mr. Frederick provided the following information:

1. Although the TMI-2 Technical Specifications required that the RCS leak rate surveillance test be conducted once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> Mr. Frederick recalled that the test was conducted daily, usually on the mid-shift.

If a successful test result was obtained on that watch, Mr. Frederick stated that he would not run it again that day. Note: The majority of operators interviewed have stated that the test was conducted once per shift, plant conditions permitting and provided the plant computer was

l i

available. Of the 25 tests involving Mr. Frederick during the period under investigation, 14 were done on the mid-shift, 9 on the swing-shift and 2 on the day-shift. Of the 11 tests performed on the day- or 1 i swing-shift, 6 times an acceptable test had been conducted earlier in i the day. In one case, 2 acceptable tests had already been conducted l that same day. The difference between Mr. Frederick's recollection of test frequency and actual test frequency may be attributed to difficulty of recall with the passage of time since the difference between daily testing and testing each shift if plant conditions are stable is not a significant difference in the number of tests performed. This is due to the high frequency of unstable plant conditions (e.g., start-ups, shutdowns, power changes, etc.) between October 1978 and March 1979.

2. Mr. Frederick stated that to the best of his recollection, he never threw away any leak rate surveillance test results. He said that all lake rate tests he ran were turned over to the Shift Foreman for his review. He did not know if they were subsequently thrown away or not.

Note: The majority of operators interviewed have indicated that invalid or unacceptable test results were routinely discarded. In a March 24, 1984 OI interview with Mr. Frederick's Shift Supervisor, Mr. Zewe, stated that the discarding of. invalid tests was accepted practice at the time. Mr. Faust also stated in his interview that invalid tests were i

routinely discarded. Thus, while it is possible that Mr. Frederick did turn all leak rate tests over to his Shift Foreman for review, it does not'seem credible that Mr. Frederick would not know that test results showing greater than 1.0 gpm for unidentified leakage were routinely thrown away.

~

3. Mr. Frederick stated that he interpreted Technical Specification 3.4.6.2 as requiring the operator to enter the Action Statement of the Technical Specification whenever they received the results of a leak rate test that exceeded the Limiting Condition for Operation, unless he could i explain why the test result was invalid. Note: The majority of l operators interviewed including Mr. Faust,"TeTieved that they were not

, required to enter the Action Statement, no matter how many bad leak rate tests were received, as long as they had not exceeded the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> required test interval without obtaining a successful test result.

While Mr. Frederick's interpretation of the requirements of the Technical Specification is correct, there is indication that Mr. Frederick did not comply with this interpretation between October 1978 and March 1979. For example, he testified that he would r.ot be i surprised if there were times when they ran a leak rate test on their shift, obtained an unacceptable result and by the end of the shift they i still had not gotten an acceptable result. Since the Action Statement i

requires that leakage be reduced within acceptable limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />. Had Mr. Frederick followed his interpretation of the requirements of the Technical Specification, as he stated, there would have been periods of tirne where the plant should have been shut down.

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4. Mr. Frederick also testified that he did not recall having difficulty getting leak rate test results within the Technical Specification limits and that if he had any problems he usually knew why. Note: The majority of operators interviewed, including Mr. Faust, Indicated that leak rate test results were difficult to get and that as the date of the accident approached, it became more difficult to get an acceptable test result. Mr. Frederick's statements regarding the difficulty of getting test results also appears to conflict with his later testimony that it would not surprise him if there were several times where they were not able to get an acceptable test result their entire shift.

5. Mr. Frederick testified that he did not log the results of leak rate tests in the CRO's Log for any tests (i.e., good or bad) because items of a routine nature were not required to be logged. Note:

_ Administrative Procedure 1012 requires that the test YTETe, test number, and the start and completion times of all surveillance tests required by the Technical Specifications be logged in the CRO's Log. Shift "A" was the only shift that did not routinely log satisfactory test results.

None of the six shifts logged unacceptable test results.

6. Administrative Procedure 1010 required that problems encountered while performing surveillance testing should be documented on an " Exception and Deficiency List." The list was to be attached to the surveillance test data sheet. Mr. Frederick stated that AP-1010 was not applied to leak rate tens, although he did not know why it had been excluded.

Note: None of the six shifts applied AP-1010 requirements to leak rate surveillance testing.

~

7. Although he vaguely recalled two other operators (Mr. Hartman and Mr. Booher) conplaining about the difficulty of surveillance testing in general, Frederick stated that he personally had no problems running the test. He attributed this to the fact he was very careful in setting up the required initial conditions for the test. He stated that he questioned all leak rate tests that were received. He stated that he could usually predict what it should be. If it wasn't what he expected, he would question it. He examined each test result carefully and if he understood it, then it was alright. Note: These statements do not coincide with the results of the technical analysis which shows that two tests were conducted during unstable plant conditions and six tests were performed using the unstable level transmitter (LT-1) as input to the computer for MUT level indication. In four of these tests of the cases, there was a significant difference between the output of LT-1 and LT-2.

Had Mr. Frederick reviewed the data carefully, as he testified, he should have seen these discrepancies.

8. Frederick stated that LER 78-62/1T neither altered his interpretation of the Technical Specification 3.4.6.2 nor did it change the way he performed the test or handled the test results. Frederick stated that he did not have a preaccident recall of the LER.

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9. With respect to hydrogen additions. Frederick stated that he was not aware prior to the accident that hydrogen additions to the MUT could-affect MUT level indication and consequently leak rate test results. He did not recall ever discussing the effect with anyone or knowing that individuals were adding hydrogen in an attempt to influence the test results. Although Frederick was told that Mr. Faust stated he (Faust) was aware prior to the accident that hydrogen additions were alleged to alter the test results. Mr. Frederick does not recall discussing the subject with Mr. Faust or any other operator. Mr. Frederick's testimony that he did not add hydrogen to mani ulate leak rate test results is consistent with NRR's technical anal sis of his leak rate tests.

10. With respect to water additions, Frederick stated that he 'never intentionally added water and not properly included the amount in the leak rate calculation in an attempt to influence the leak rate test results. He also stated that he was not aware of other operators manipulating tests in this manner. Note: Although, water additions, that were not completely accounted f F Tn the test calculation, occurred during three of Mr. Frederick's tests, there are credible reasons why that may have accidently occurred. In addition..the number of tests .

performed by Mr. Frederick, during the high identified leakage period of February and March 1979, where water was added and properly compensated for, supports Mr. Frederick's testimony.

In sunrnary, the technical analysis supports Mr. Frederick's testimony that he did not intentionally add water and/or hydrogen to the MUT during the leak rate tests for the purpose of manipulating the test results. However, other aspects of his testimony dealing with difficulty in obtaining satisfactory -

test results, the disposition of unsatisfactory results, and his overall knowledge of leak rate testing irregularities raise questions regarding the

, accuracy of his responses during the interview.

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\

l NOTE: This enclosure discusses information that is maintained in the NRC's Privacy Act System of Records (NRC-16). This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO. Internal access and distribution should be on a "need to know" basis.

Enclosure 2 ,

I. Background On January 31, 1985, an interview was conducted with Mr. Edward R. Frederick,

.a Senior Reactor Operator at Three Mile Island Nuclear Station, Unit 2, in order to determine Mr. Frederick's understanding of his responsibilities for the safe operation of the plant and his comitment to those procedures and .

operating principles necessary to carry-out those responsibilities.

Participating in the interview from the NRC were William Russell, Deputy Direqtor, Division of Human Factors Safety and Leonard Wiens, Senior Examiner, Operator Licensing Branch. Mr. Smith B. Gephart and Mr. James

- Moeller, attorneys representing Mr. Frederick, were also present at the -

interview.

In addition to the interview with Mr. Frederick, interviews were conducted with Mr. Frederick's supervisors on January 30, 1985 and February 1, 1985.

Supervisors interviewed include:

Name Position / Title B. Long Vice President-Nuclear Assurance S. Newton Manager, Plant Training D. Ross Manager, Corporate Training Section II provides a sumary of the interviews with Mr. Frederick and the .

supervisors identified above.Section III provides an overall conclusion regarding Mr. Frederick's current performance.

II. Interview Sumary -

Mr. Frederick appeared to be a sincere, conscientious and dedicated operator.

Although at times he seemed hesitant in his answers, this hesitation appeared to have been the result of careful consideration of each question and his answer before giving his answer. Although'his primary duty involves train-ing, he appeared to be very knowledgeable of shift operations. He generated an overall impression of great sincerity and as someone who naturally accepts complete responsibility for his actions.

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III. Conclusion No information was obtained from the interviews with Mr. Frederick -

t concerning Mr. Frederick's current performance which could be used as a basis for revocation or modification of Mr. Frederick's Senior Reactor Operator's License.

The Senior Operator Upgrade. Examination Report used to record the results of Mr. Frederick's interview is included as Attachment 1 to this enclosure, and the list of questions asked of Mr. Frederick is included as Attachment 2. .

O 9

e

,t .

Enclosure 8 8  % n UpflTED STATES NUCLEAR REGULATORY COMMISSION

$ t WAmetseeTON, D. C. 30504 l

(*...*[ October 9,1985 MEMORANDUM FOR: Harold R. Denton, Director .

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

SUBJECT:

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

Reference:

1.~ Memorandum from S. J. Chilk (SECV) to B. 8. Hayes (01) and W. J. Dircks-(EDO) dated April 2,1984.

Subject:

Staff Requirements-Discussion of Pending Investigation-TMI

2. Memorandum from H. R. Denton (NRR) to B. 8. Hayes (01) dated May 3, 1984.

Subject:

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

3. MemorandumfromW.T. Russell (DHFS)toH.R.Denton (NRR)datedJanuary 24, 1985

Subject:

Follow-up Action on Additional TMI-2 Operators The purpose of this memorandum is to document the results of the joint 01/NRR investigation and evaluation of Mr. Carl L. Guthrie, a licensed Senior -

Reactor Operator (3RO) at Three Mile Island Unit 2 (TMI-2), currently serving as Foreman, Radwaste Operations THI-2. and to provide a reconenendation regarding whether his current SRO license should be revoked, modified, or suspended under 10 CFR 55.40 or other enforcement action taken under 10 CFR Part 55.50. due to his involvement in preaccident leak rate testing irregularities at TMI-2.

Background

As the result of a Commission meeting on March 23, 1984 NRR was directed by Reference 1 to review 01 investigative materials concerning falsification of reactor coolant system (RCS) leak rate tests at THI-2 and refer back to OI NOTE: This memoran3um and Enclosure 1 discuss infomation which is the sub-ject of an ongoing 01 investigation. This memorandum and Enclosure 2 discuss infomation that is maintained in the NRC's Privacy Act System ofRecords(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.

-] J i - d

. s I ,[(]fh3

Harold R. Denton ' October 9, 1985 those matters which required further investigation. The_results of NRR's i review was provided in Reference 2. The review detemined that follow-up investigation was warranted in the case of seven operators who were currently licensed. Mr. Guthrie was not one of those seven individuals.

At a follow-up Comission meeting on May 23, 1984, the Comission. agreed with the approach of evaluating past and present perfonnance. OI and NRR would conduct a joint investigation to detemine what role, if any, these individuals had in improper activities associated with leak rate surveillance testing at THI-2 prior to the accident and NRR would conduct an evaluation of i

the current perfomance of these individuals. Based upon the results of the i investigation and evaluation, NRR would recommend to the Comission what action, if any, should be taken against each of the identified operators.

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

t Of the ten individuals identified for investigation and evaluation, seven are currently licensed on TMI-2 and one is licensed on San Onofre 2 and 3. The remaining two individuals we're licensed on Waterford 3, but have recently

terminated their licenses and are no longer employed by Louisiana Power &

Light Company.

past Involvement in TMI-2 Leak Rate Testing Irregularities 1

On June 4,1985, a joint O!/NRR interview of Mr. Carl L. Guthrie, was held at the Three Mile Island Training Facility, Middletown, Pennsylvania. The l

interview was conducted in the presence of Mr. Guthrie's personal attorney.

The purpose of the interview was to detennine Mr. Guthrie's role, if any, in improper activities associated with RCS leak rate surveillance testing at i TMI-2 prior to the accident on March 28, 1979. At that time, Mr. Guthrie was a Shift Foreman assigned to three different shifts; however, during the last three months of operation he was assigned to Shift "F." A detailed evaluation of Mr. Guthrie's involvement in leak rate testing irregularities l

is provided in Enclosure 1 to this memorandum.

j During the interview, most of Mr. Guthrie's responses to general questions associated with RCS leak rate surveillance test problems at TMI-2 were consistentwiththetestimony(ofotherlicensedoperators,inc?udingthe three Control Room Operators CR0s) assigned to shift "F," Mr. Guthrie admitted that many of his actions, associated with the supervision of leak rate testing, violated approved plant procedures and technical specifications; however, he denied any personal involvement in or knowledge l

of leak rate test manipulation.

Based upon the results of NRR's technical evaluation and the testimony of Mr. Guthrie and the other operators on his shift (Messrs. McGovern, Hemila i

and Gemer), 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.

t O

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- - - ...-.--.---,..--nme ,c ---,,.y-, , - , - - ,- - - . - vm. - _m--., - - . , . _ - - - -

Harold R. Denton October 9,1985

2. Contrary to Technical Specification 6.10.1.d " Record Retention " leak rate tests indicating unidentified leakage in excess of I gpm were .

discarded, either directly by Mr. Guthrie or his CR0s.

3. Contrary to Surveillance Procedure 2301-3D1, "RC System Inventory " and contrary to the licensee's stated corrective action in the LER 78-62/1T, when test results indicated unidentified leakage in excess of the limiting condition for operation (i.e.,1 gpm), Mr. Guthrie did not enter the action statement of Technical Specification 3.4.6.2, " Reactor Coolant System Operational Leakage." Mr. Guthrie testified that after October 1978, he was aware that action was required: "I probably felt personally that we weren't really adhering to the letter of the law."

4. When leak rate test results exceeded the limiting condition for 4 operation of Technical Specification 3.4.6.2, Mr. Guthrie brought it to the attention of his Shift Supervisor. He was told to run another test and contiriue to look for leaks. According to Mr. Guthrie, it was a ~

conscious decision by the Shift Supervisor not to enter the action statement of the technical specification. Mr. Guthrie stated that this practice may have been known and condoned by the Supervisor of Operations and possibly higher levels of management.

5. Although Mr. Guthrie advised the Shift Supervisor of unsatisfactory leak

! rate test results, contrary to TMI Administrative Procedure 1010, l " Technical Specification Surveillance Program " he did not complete

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

! 6. Contrary to TMI Administrative Procedure 1012. " Shift Relief and Log Entries " Mr. Guthrie was aware that CR0s were not logging the start ,

time, stop time and the results of all leak rate surveillance tests in l the Control Room Log.

7. Mr. Guthrie testified that he was aware of periodic problems with the make-up tank (MUT) level transmitters and advised his CR0s to perform tests using the stable level transmitter. Nevertheless, the NRR evaluation shows three of the tests approved by Mr. Guthrie were run with j an erratic and unreliable level transmitter providing MUT level

{ indication to the computer.

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

, consequently leak rate test results. However, Guthrie also stated he l had no personal knowledge of any operator using hydrogen to manipulate test results. The NRR evaluation showns that two tests and possibly one additional test, approved by Mr. Guthrie, involved hydrogen additions j during the leak rate test period.

9. Mr. Guthrie testified that he had no personal knowledge of any operator .

4 adding water during the course of a leak rate test and not including the j amount added in the calculation. The NRR evaluation shows one possible

test, approved by Mr. Guthrie, where water may have been added and not

included in the calculation. This test may have involved a hydrogen addition rather than a water addition. It is not possible from the records available to differentiate between water or hydrogen for this t

particular test, (see also item 8 above).

i i - , . - _ . , _ _ - _ - . - . - _ _ _ - , -

Harold R. Denton October 9, 1985

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

He did not believe his CR0s were aware of this problem either and did not believe they would take advantage of such an inaccuracy during the perfonnance of leak rate tests. The NRR evaluation shows three of the tests approved by Mr. Guthrie, involved water additions, where the amount of water logged in the CR0's Log 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. Guthrie or his CR0s knew of the instrument inaccuracy at the time and used it to their advantage.

3 In sumary, Mr. Guthrie agrees in retrospect that many of his actions

, involving leak ratt surveillance testing at TMI-2 violated approved plant procedures and were contrary to the TMI-2 Technical Specifications. Because of problems with instrumentation and the procedure itself, it appears Mr. Guthrie considered the test unreliable as far as representing true plant

, leakage. When leakage above the limits of the technical specification were brought to the attention of his Shift Supervisor, Mr. Guthrie was instructed i to run another test, and to continue to look for leaks. As a result of test

! problems and the lack of management concern for the test, he treated the test i as an administrative requirement only.

While 12 of the 19 tests involving Mr. Guthrie during this period are i considered invalid, and one additional test was not signed because it exceeded the limits of the technical specifications, there is insufficient

evidence to conclude that these tests were intentionally manipulated.

Rather, it appears that because tests were conducted so frequently, the CR0s did not worry about establishing the proper steady-state conditions required for the test, and Mr. Guthrie's review only involved looking at the " bottom i line" test results. Thus, if a test result was greater than 1 gpm, it would be discarded and another test would be started. If a test was less than I gpm, it would be retained with little or no review to ensure it was a valid test.

j Current Perfomance On June 4, 1985, NRR conducted an interview and oral examination of

, Mr. Guthrie in order to detemine his understanding of his responsibilities for the safe operation of the plant and his commitment to those procedures and operating principles necessary to carry out those responsibilities. In order to obtain additional background infomation on Mr. Guthrie's current

performance, joint TMIP0/NRR interviews were conducted on May 17, 1985, with GPUN Site Operations Management and the NRC's Resident Inspectors for TMI-2.

Enclosure 2 to this memorandum contains the evaluation of Mr. Guthrie's current perfomance as well as: (1) a sumary of the background interviews; (2) the Senior Operator Upgrade Examination Report used to record the results

, of Mr. Guthrie's interview; and (3) a copy of the questions asked of Mr. Guthrie and a sumary of his responses.

In general, Mr. Guthrie appeared to be a cautious operator with a i

satisfactory knowledge of operating procedures and administrative i

i

.rg, , , . , _ , . - - . - . - . . , .

Harold R. Denton

• ip. 'e-5 . * .y  % -

October 9. 1985 requirements in effect at TMI-2. He demonstrated excellent judgment when placed in hypothetical situations which did not have clearly correct solutions. In those areas in which he demonstrated some weaknesses, it was apparent that he would readily admit to such lack of knowledge and seek i assistance from more knowledgeable operators. He expressed a casunf tment to i strict compliance with procedures, and his responses during the interview  ;

indicated that all of his actions on shift would be based upon strict {

procedural compilance.

1 1

The overall impression of Mr. Guthrie was that he is an average operator. 1 somewhat lacking in confidence, but with the casunon sense to request assist-ance when necessary. The. background interviews conducted with Mr. Guthrie's supervisor and the NRC Resident Inspectors support this observation. . '

In susunary, no infonnation was obtained from the interviews with Mr. Guthrie. ~

. which could b'e used as a bas.is for revocation or modification of his Senior Operator License.

Conclusions and Recomunendation During the period under investigation, while Mr. Guthrie served as a Shift Foreman, he admitted being involved in activities associated with reactor coolant system leak rate testing that were in violation of approved plant procedures and the TMI-2 Technical Specifications. These actions included:

1. Failure to ensure that leak rate surveillance tests were conducted in accordance with the approved plant procedure.

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

I

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

I

4. Fai1ure to retain leak rate tests whose results exceeded the limiting j conditions of operation of the technical specifications, and

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

2 Despite these actions. Mr. Guthrie denies that he was involved in or was

! knowledgeable of any activities on the part of operators or supervisors to intentionally influence or manipulate the outcome of leak rate test results.

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

, leak rate test manipulation; however, the evidence supports a finding that

! Mr. Guthrie was grossly negligent in his duties as a Shift Foreman with respect to supervising leak rate surveillance testing and initiating required i follow-up action.

l 1

~m i

l m) .................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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OFFICIAL RE' CORD COPY _ ,

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Harold R. Denton October 9.1985 In trying to balance Mr. Guthrie's past involvement in improper activities with his current perfonnance, it is necessary to consider factors that may have influenced his earlier actions. Based upon Mr. Guthrie's testimony and the testimony of other Shif t Foreman and Control Room Operators interviewed to date, it is clear thatrnanagement's standards for procedural compliance were lax and permissive. In my opinion, this was created through negligence on the part of man &gement. When leak rate surveillance tests that exceeded

', the limits of the technical specification were shown to Mr. Guthrie's Shift Supervisor, the only instructions given to Mr. Guthrie were to run another test and continue to look for leaks. This conscious decision by Shift Supervisors, and possibly management personnel, to disregard the requirements of the technical specifications coupled with the lack of respect for the leak 1 rate test procedure and 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 nome cases motivated operators to manipulate or falsify leak rate test results. .

] Mr. Guthrie may not have been involved in or condoned leak rate test

annipulation; however I believe he approved and submitted test results J #ithout regard for their validity, as long as the calculated unidentified eskage was below the technical specification limit. In some cases he nowingly violated the technical specifications by failing to enter the

, -tion statement when leak rate tests results exceeded the lie.iting widitions for operation.

^ I believe that Mr. Guthrie has learned from his past mistakes, does understand his duties and responsibilities for conducting safe operations at TMI-2, and that he is comitted to following approved procedures and principles necessary to carry out those responsibilities. I also believe that he -

imparts this same sense of responsibility to his subordinates.

1 i In sumary, I reconsnend that no enforcemeint action i be tak'en against Mr. (utfirie.

~

, Crigir.tI Si7.ed 37

! CI *.: * *: 7. L'.:,II.:.

l William T. Russell, Acting Director

! Division of Human Factors Safety Office of huclear Reactor Regulation

Enclosures:

1 As stated cc: 8. Hayes

v r w .-a ..

l em pl , , . . , ...,.............,..................... ..................... . . " . . " ~ ~ ~ ~ . " ~""""".".

i *ec eo= = m . o..o. .c. on.o OF'FICIAL RECORD COPY **'"""-*"4 l

.o .

i NOTE: This enclosure discusses information which is the subject of an ongoing 01 investigation. This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO or the Director 01. Internal access and distribution should be on a "need to know" basis.

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

1. Backoround On June 4,1985, a joint Office of Investigations ('0!h0ffice of Nuclear ~

Reactor Regulation (NRR) interview with Carl L. Guthrie was held in the Three Mile Island Training Facility, Middletown, Pennsylvania. The purpose of the interview was to determine Mr. Guthrie's role, if any, in improper activities associated with reactor coolant system (RCS) leak rate surveillance testing at Three Mile Island, Unit 2 (TMI-2) prior to the accident on March 28, 1979.

Present during the interview representing the NRC we're: R. Keith Christopher, Director. Office of Investigations, Region I; William T. Russell. Acting Director. Division of Musan Factors Safety; and Robert A. Capra. Senior Program Manager, Generic Requirements and Regional Operations Staff.

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

Smith 8. Gephart of the law firm Killian & Gephart, Harrisburg. Pennsylvania.

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

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

Mr. Guthrie began his employment with Metropolitan Edison Company (Met-Ed) en February 2.1971, as an Auxiliary Operator (AO). He was initially licensed i

as a Reactor Operator (RO) on TMI-1 in August, 1975. After receiving his SRO Itcense in July, 1975, he was promoted to Shift Foreman TM!-1. In August, 1977, he received his SRO license on TMI-2 and was assigned as Shift Foreman

• TMI-2. Mr. Guthrie remained in that capacity until after the accident on j March 28, 1979.

The interview with Mr. Guthrie concentrated on the period September 30, 1978

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

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

Guthrie is provided in Section !! of this enclosure. A sumary of the interview with Mr.' Guthrie is provided asSection III. The sumary of interview section includes citations to the page numbers of the transcript from which the sumarized infonnation was extracted. Overall findings and conclusions regarding Mr. Guthrie's involvement in improper activities associated with TMI-2 leak rate surveillance testing are presented in Section

, IV of this enclosure.

i t

E. _ . _ __ _ _ _ _ _ . _ . _ _ __ _ _

II. Sumary of the Technical Analysis In 1983 and 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 Department of Justice (00J) in its criminal proceeding against Met-Ed. In 1985, NRR performed a reevaluation of that analysis by factoring in information that was learned during interviews with former TMI-2 operators.

Mr. Guthrie was questioned on the updated 1985 analysis. While a copy of the complete evaluation of leak rate tests at TMI-2 is provided as Attachment 2 i

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

GENERAL

- In order to demonstrate that reactor coolant system (RCS) leakage did not '

4 exceed the limiting conditions for operation. TMI-2 Technical Specification 3/4.4.6.2 RCS water"inventory Reactorbalance Coolantleak Sy(stem rate test) Operational be performed Leakage,"

at least once directed every that a i

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 i

the operator to avoid the addition and removal of water from the RC and make-up systems during the test including: make-up or chemical addition to

the make-up system or boration/deboration. In addition, the operator is

, 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 pressurizer 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 would be signed by the operator performing the test and approved by an SRO.

In most cases, the Shift Foreman approved tests run on his shift. The test records show that of the 161 leak rate surveillance tests retained by the licensee during the period under investigation, Mr. Guthrie was involved in 19 leak rate surveillance tests. The table below shows a breakdown of NRR's t

overall conclusions regarding these tests. '

Breakdown of Leak Rate Tests Involving C. L. Guthrie Evaluation Category Number of Tests Total number of tests on fi1e............................ 19 Tests with no apparent problems................................... .......... 6 Unstable or inaccurate data provided to the plant computer......... 4 Water additions to make-up tank (MUT) (partially included in the calculation).....................................................

Hydrogen additions to 3

MUT................................. ........ 2 Water or hydrogen addition to MUT (unable to differentiate)........ 1 Feed and bleed operations (not included in the calculation ........ 1 Uns ta bl e pl a n t cond i ti ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. . . .) . . . . . . . .

un,dentified ieakage greater tnan the TS iimit..................... 1

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

Guthrie appear to have been conducted in accordance with the requirements and precautions of the surveillance procedure governing the conduct of leak rate tests (SP 2301-3D1). Of the 13 remaining tests, one unsigned and unapproved

test exceeded the acceptance criteria for unidentified leakage, while the t

ot5er 12 tests involve either actions that violate the limits and precautions cf the procedure or were performed with unreliable or inaccurate data being l supplied to the plant computer, thus, yielding questionable or invalid -

results. The basis for the evaluation of each test is presented below.

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

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

f UNIDENTIFIED LEAXAGE GREATER THAN 1 GPM Test #12C(10/18/78), indicating unidentified leakage of 1.77 gpm, was i conducted while Mr. Guthrie was the Shift Foreman, but was neither signed by the operator performing the test nor approved by Mr. Guthrie. This test was conducted when the plant was experiencing high leakage (gross leakage of i approximately 4.0 gpm). The surveillance test was not flied with the other surveillance tests maintained by the licensee. Instead, this test was filed with a set of tests associated with the submission of LER 78-62/1T on November 1, 1978. The significance of the LER is discussed during the interviewwithMr.Guthrie(SeeTranscriptpages34through43).

l UNSTABLE PLANT CONDITIONS

) AccordingtoentriesintheControlRoomOperator's(CRO)LogandtheShift Foreman' slog. Test #40(11/09/78) was conducted during a sodium hydroxide (Na0H)flushofthedecayheatremovalandmakeupsystems. MUT level changes of 2 6" (180 gallons) during the test are believed to be the result of this

. operation.

, INSTRUMENTATION PROBLEMS i At TM1-2 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

level strip chart recorder in the control room while the other level .

I transmitter provides MUT level indication to the plant computer. A selector

! switch in the control room allows the operator to switch level transmitters

! feeding the strip chart recorder and the plant computer. When the selector j switch is positioned to LT-1, the strip chart recorder is driven by the 1 l output of LT-1, and LT-2 provides automatic input to Se plant computer for ,

! leak rate test calculations. When the selector switch is changed to LT-2, j the opposite would occur.

Between October 30 and November 6, 1978, operators experienced problems with

.I both level transmitters. At various times during this period, the level l transmitters were reading radically different levels in the MUT and both were taken out-of-service for maintenance work and recalibratien. During this period Mr. Guthrie approved leak rate test W34 (11/03/78). At the tire of i

I *

)

the test, the operating level transmitter providing input to the strip chart recorder was reading approximately 80", while the level transmitter providing input to the plant computer for the leak rate test was essentially reading y off-scale high at 99". -

j Beginning in early December,1978, and continuing through Januar'y 11,1979,

! the output of LT-1 became very erratic and unreliable. Because of the i 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. Guthrie was involved in the approval of three tests. Two of the tests

, were run with LT-1 providing input to the computer. #73 (12/23/78) and #74 l (12/24/78).

For test #74, the differences between the initial and final va. lues of MUT.

]

~

level for LT-1 and LT-2 are small; therefore, the use of LT-1 in this case, may not have produced a significant error in the leak rate calculation.

However, for Test #73, the use of LT-1 allowed the computer to read the one hour change in MUT level as +.542" instead of an actual value of approximately -2.0" as shown by LT-2. In addition to these tests which were approved by Mr. Guthrie, two other tests, #64 (12/16/78) and #80 (12/30/78),

which utilized the bad level transmitter, were conducted while Mr. Guthrie t was on shift. Test #64 was completed on Guthrie's shift but was approved by the on-coming Shift Foreman (Ken Hoyt) after Mr. Guthrie was relieved. Test

+

1. 80 was started on Mr. Guthrie's shift but completed by Shift "C" and approvedbytheirShiftForeman(ChuckAdams).

'; In sumary, during the entire perio'd of time LT-1 was essentially "out-of- l comission," all shifts, including Mr. Guthrie's, continued to run leak rate

' tests (34 out of 50) with LT-1 providing MUT level indication to the computer. These actions resulted in a meaningless calculation of

- unidentified leakage that could not demonstrate conformance with the **

technical specification limit of 1 gpm.

Test #41(11/22/78) provides another example of obvious instrumentation problems. The test was signed by the operator performing the test and approved by Mr. Guthrie despite the printed value of Loop A, hot leg temperature printing out in dollar signs ($) and a value for Tave of -17'F.

FEED AND BLEED OPERATIONS -

1 One test, #106 (02/06/79), approved by Mr. Guthrie, contains a possible feed j and bleed operation that was not taken into account in the leak rate test

calculation. Approximately 20 minutes after the start of the test, MUT level i

dropped approximately g" (270 gal) and then slowly increases 7" by the end of

the test. The change appears to be the result of either a feed and bleed operation or control rod movement. Entries in the CR0's Log and the Shift l

Foreman's Log do not provide an explanation for this change; reactor control i (" diamond") was in manual during the test period due to an electrical problem with Group 7 control rods.

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

i appears to have have been started during the bleed portion of a feed and

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

HYDROGEN ADDITIONS i

In order to limit the oxygen content in the RCS and to provide an increased i

t net positive suction head for the RCS makeup pumps, a hydrogen overpressure was maintained in the MUT. When hydrogen pressure decreased near the low end of the operating band, the CR0 would add hydrogen to the tank. Theoretically, the addition of hydrogen should not have affected MUT level; however, because 1

of the configuration and environment of the MUT level detection -

instrumentation system at THI-2, water could collect in the low-pressure l (dry) referepce leg of the level transmitters. Under these conditions, the resultant water slug or " loop seal" could cause a temporary increase in the j

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 i

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 si.e., the calculated leak rate would be less

thantheactualleakrate).

Two tests have logged hydrogen additions during the test period, #17 (10/20/78)and#1$2(03/21/79), and one test, #121 (02/16/79), is believed to l contain either a hydrogen addition or an unaccounted for water addition.

One minute after the start of Test #17, the CRO's Log states the MUT was i vented. Sixteen minutes later hydrogen pressure was increased to 18 psig and 5 minutes before the end of the test an unspecified amount of hydrogen was, again added to the MUT. The net affect on the leak rate test results is uncertain since MUT level decreased approximately 6" during the test while pressurizer level (Lp) increased 10.5".

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

• during the test. Approximately halfway through the test there is a 2" rise *

(60 gal) in MUT level indication that can not be accounted for by changes in

i. Tave or pressurizer level. The characteristics of the MUT level trace are

) -

very similar to Test #120. Test #120 was performed by the shift Mr. Guthrie relieved (Shift "C") and involved an experimental addition of hydrogen by the CR0s and the Shift Foreman (Chuck Adams) in order to determine the effect of

hydrogen on leak rate test results.

i Test #152 contains a water addition and a hydrogen addition. According to the CRO's Log, Twelve minutes after the start of the test 200 gallons of water was added to the MUT. A total of 207 gallons was included in the test calculation. The actual amount seen by the MUT level transmitter was 210 gallons. Although the need for the water addition during the test is not clear, it appears to be properly accounted for in the test calculation.

i However, nine minutes before the end of the test hydrogen was added to the MUT and recorded in the CR0's Log. The net effect of the h

(

was a rise in MUT level of approximately 2" or 60 gallons. ydrogen addition l

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

. l WATER ADDITIONS Because adding water to the MUT compresses the hydrogen gas in the top of

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

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

,, in the loop seal, the indicated level on the MUT strip chart might actually 1 increase 6 inches (180 gal). Once the final data was read by the computer.

! including the 6 inch rise in MUT level, the operator would enter the 150

' gallon water addition into the computer as an operator-caused change. Thus.

when the computer calculated the net unidentified leak rate, the leak rate resultwouldbe0.5gpmlessthantheactualleakrate[(180 gal-150 gal)/60 i

minutes].

Former TMI 2 CR0 Mark Coleman (Shift *0") stated during his joint 01/NRR l interview on December 14. Ig84, that he was aware of this phenomenon and l intentionally added water near the end several leak rate tests in order to i take advantage of this phenomenon to help his get tests results within the limits of the technical specifications. The technical evaluation of leak rate tests performed by Mr. Coleman's shift supports his testimony. As shown by the chart below, three of the last four tests prior to the accident approved by Mr. Guthrie, exhibit the same characteristics as Mr. Coleman's i tests.

j computer nuI strtp trror Time before j Test # Date Inout Chart Produced End of Test CRO-Test CRO-Panel

. . 150 03/17 207 gal 240 gal 33 gal 24 mins McGovern Hemila 151 03/19 200 gal . 330 gal 130 gal imin McGovern Hemila l

l 153 03/22 200aal 300aal 100aal 7 min McGovern Hemmila l Key: Comouter Input = amount of water included in test calculation by CRO.

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

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

i Time Before End of Test = time before end of test that water addition  :

i was made or time of last water addition if more than one addition I

occurred during the test.

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

CRO-Panel = CR0 who was on the panel during test and who signed the GRD's Log.

j As stated earlier in this section. SP 2301 3D1 cautioned the operators te

avoid the addition and removal of water from the reactor coolant and makeup i systems during leak rate tests. However, during the last two months of l l' operation leakage frem the top of the pressurizer from either the PORV  !

and/or safety valves increased. As a result, operators were forced to add a i

i

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

In sumary, the technical evaluation shows that between September 30, 1978 and March 29,1979,13 of the 19 tests (685) involving Mr. Guthrie included actions that were contrary to the precautions, limitations and requirements of Surveillance Procedure 2301-301. These actions included: ignoring test '

results greater than the technical specification limit; approving a test conducted during unstable plant conditions; approving tests that utilized unreliable or inaccurate MUT level or temperature instrumentation as input to the plant computer; approving a test conducted during a feed and bleed operation; approving tests containing water additions that were affected by MUT level irstrument inaccuracies; and approving tests during which hydrogen was added to the MUT. Based upon the high number of questionable or invalid tests, it appears that the tests were accepted as valid as long as the results were less than the technical specification limit, regardless of the evolutions in progress during the tests. Nevertheless, there is no clear pattern that these evolutions were performed with the intent of wrongfully influencing leak rate test results. In addition, while some of these actions i

i challenge the validity of certain tests, they did not always produce leak rate test results that were lower than would otherwise have been the case.

! III. Interview Summary During the period under investigation, September 30, 1978 through March 28, l 1979. Mr. Guthrie indicated that he was a Shift Foreman assigned to several.

! different shifts. On January 1, 1979, when a sixth shift was created (Shift

"F"),GuthriewasassignedaShiftForemanforthatshift.je,,,e,pages5and6.

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

following shifts during the period under investigation l

i POSITION SHIFT "E" 5HIFT "A" 5HIFT "F" l 10/78 11/78 1Z/75 01/79-03/79

! Shift Supervisor: Bernie Smith Bill Zewe Ken Bryan Shift Foreman: Carl Guthrie Carl Guthrie Carl Guthrie CRO: Ray Booher Ed Frederick Hugh McGovern CRO: Harold Hartman Craig Faust Earl Hemila CRO: Lynn Genner* Hugh McGovern Lynn Germer*

CRO: John Blessing *

! *Intraining(notlicensed) i l I

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

_ - _ - - -- - - _ . - . _ -. ___. - -__ ~_- . _ _ _ _ ._ - _.

\

4

. g. I 2

he believed he was cognizant of everything that the CR0s were doing during the shift. As Shift Foreman, Guthrie 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. M pages 6-8. '

Guthrie stated his interface with plant and station management was limited.

When he was on day shift, he would usually see the Supervisor of Operations l

(Jim Floyd) and the Plant Manager (Joe Logan) and would answer any questions

)

they may have; however, most operational matters went through the Shift Supervisor. His contact with the Superintendent of Technical Support (Jim Seelinger) and the Station Manager (Gary Miller) was infrequent.

- to Guthrie, the Shift Foremen tried to meet every four to six weeks toAccording discuss day-to-day operational problems; but, Guthrie did not recall members of plant or station management being present at those meetings. See pages 8-11. ,

i After reviewing a copy of TMI-2 Technical Specification 3/4.4.6.2, " Reactor '

~

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

1. M pages 12 and 13.

4 Mr. Guthrie stated that there were problems with the computer program for

obtaining leak rates; as a result, the test was not considered reliable. He i stated test results showed a lot of data scatter. Sometimes the results would show a negative leak rate and at other times the test would indicate a large positive leak rate that did not accurately reflect plant conditions.

l Guthrie stated that Mr. Bill Falls was the principal person assigned to try and resolve some of the problems with the program. Guthrie was quite sure.

that everyone in the Operations Department, including the shift Supervisors l and the Supervisor of Operations, was aware of the problems. jge,pages

13-17.

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

" switching and tagging" duties and not the operator assigned to the control panel. The operator performing the test would try and keep the panel operator advised that the test was in progress, in order for him to try and keep the plant in a stable condition for the duration of the test. Following completion of the test, the operator performing the test would: evaluate it; sign the surveillance test sheet; inform the panel operator of the test results; and provide it to the Shift Foreman for his review and approval.

Because of the routine nature of the test, at times Guthrie was not aware a test had been run until he was provided with the surveillance sheet. See pages 17-19.

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

=--,.m.=. - + - -v-,-.. --ew,,-a wee m w,.e rww.wm . ._,,,,w-- ..iw

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When asked how leak rate tests would be evaluated, Mr. Guthrie stated he i would review the test results against the acceptance criteria. The acceptance criteria required that identified leakage be limited to 10 gpm and

unidentified leakage be limited to 1 gpm. He said that leak rate tests, whose results were greater than the technical specification limit for ,

unidentified leakage, were given to him on occasion. If operator-caused i changes invalidated a leak rate test, the procedure required that the evolution causing the test to be declared invalid, be documented in the remarks section of the data sheet. Guthrie stated, that portion of the

{ procedure was not followed. He said that in most cases, when test results exceeded the technical specification limit, they would try and determine the i source of the leakage by running another test and dispatching operators to look for possible leakage in the plant. jggpages20-25.

I At certain times, Guthrfe stated, looking for leaks was an ongoing task.

There were periods where unidentified leakage exceeded the technical specification limits and they were not able to identify the source of the-leakage. In these cases, the Shift Supervisor would assess whether it was 1 .

] safe to continue operation. Regardless of the evaluation, Guthrie stated t

leak rate test results in excess of the technical specifications were l discarded and another test would be conducted. jgepages20-24.

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

, valid if it came out less than 1 gpm Mr. Guthrie said that was done because of the lack of confidence in the test. From other instrumentation in the

! plant, it was not possible to prove or disprove that the number printed on

the surveillance test sheet was a valid number. je,e,pages25and26.

While Mr. Guthrie stated that there were other methods which indicated l primary plant leakage such as: reactor and auxiliary butiding sump levels -

l MUT level indication, and reactor building radiation monitors, he admitted l

that the leak rate test was the only method available to quantify

. unidentified leakage in order to demonstrate compliance with the technical specifications, jgtpages26and27.

• 1

! Mr. Guthrie was asked who authorized the throwing away of surveillance tests i

that did not meet the acceptance criteria of the technical specifications.

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

Supervisor knew of the practice because he would personally shown him  !

1 unsatisfactory test results. Many times the Shift Supervisor's only response was: run another test, go out and look for leaks, and make reactor building ,

[ entries. Guthrie believed the Supervisor of Operations was also aware of I this practice. Mr. Guthrie stated that leak rate tests were unique and did f i not believe other surveillance tests were treated in this manner. jeepages

28-30.

i

! Mr. Guthrie was aware, that as Shift Foreman, it was his responsibility to l ensure his shift complied with the technical specifications. He also i understood that if unidentified leakage exceed 1 gpm, he was required to enter the action statement of Technical Specification 3.4.6.2.

i i Note: Action statement b of Technical Specification 3.4.6.2 states: "With  !

l any Reactor Coolant System leakage greater than any one of the above limits, excluding PRESSURE BOUNDARY LEAKAGE, reduce the leakage rate to within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least HOT STANDBY within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUTDOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />."

+ . _e-- ._ _ .ww---wy,~

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Despite receiving test results in excess of the technical specification limits and understanding his responsibilities as Shift Foreman, Mr. Guthrie did not believe he ever entered the action statement. hepages31-33.

Mr. Guthrie stated that while it was his responsibility to ensure compliance with the technical specifications, unless there was a dire emergency requiring 1sunediate shutdown, it was the Shift Supervisor's decision whether the plant should be shutdown. Guthrie had discussed this situation with his Shift Supervisor. His Shift Supervisor was aware of the technical specification limits and Guthrie had shown him leak rates that were in excess i

of those limits. Guthrie was then asked if he was saying, it was the Shift l Supervisor's decision not,to comply with the requirements. Guthrie responded by stating: "Not so much not to comply with it but to interpret it the way it

! was interpreted...if they could get one within every seventy-two hours that i i

they met the requirements." h e,pages 33 and 34. .

A copy of LER 78-62/1T, along with an attached routing sheet, was provided to

. Mr. Guthrie for his review. The routing sheet was used to indicate which individuals had seen the LER. Guthrie had initialed the routing sheet and recalled seeing the LER prior to the accident, hepages37and38.

i Note: On October 18, 1978, during a routine inspection of TMI-2 operations,

) an NRC inspector discovered several bad leak rate tests lying in the i

control room and that TMI-2 had been operating for an extended period of time with unidentified leakage exceeding the technical I

specification limit. The incident resulted in the submittal of LicenseeEventReport(LER)78-62/1T.

1 The LER stated in part: "This event was caused by a misinterpretation

of the requirements of the technical specifications....The appropriate personnel will be instructed on the requirements of applicable sections of the T.S. and the requiremerts to isinediately invoke applicable actions statements when the provisions of the LCOs [ limiting conditions for operation] are not met."

! Mr. Guthrie October 18,1979, was (Test shown a copy)of

1. 12C a leak

, while Mr. ratewas Guthrie testthe thatShift wasForeman started on at 0513 on 1 watch. It was pointed out to Mr. Guthrie that this is believed to be one of the leak rate tests that was seen by the NRC inspector on the morning of October 18th. The test indicated unidentified leakage of of 1.77 gpm and was

not signed by the operator running the test or approved by Mr. Guthrie.

Handwritten consnents on the test state: " rounds off high but is corrected by .

leak rate 10/IP!78 7:35:27 start time, i.e., into action statement at 5:13:02

! out of it at 7:35:27." Although he would normally be informed of all test

results that exceeded 1 gpm, Guthrie did not recall seeing this particular surveillance test sheet prior to the accident. Se,pages35-36,3g.40. e

! As a result of this incident Mr. Guthrie recalled being aware that they had  ;

! been misinttrpreting the requirements of the technical specifications and '

that anytime they received a leak rate test in excess of the limiting ,

! condition for operation, they were required to enter the action statement of I l the technical specification. hepage41. e , l i

l

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

order for him to enter into the action statement. He responded. by saying no, and that in retrospect, they should have entered the action statement; however, management did not agree. By management, Guthrie said he meant the Shift Supervisors, the Supervisor of Operations (Jim Floyd), the Plant

Manager (JoeLogan),andtheVice-presidentforGeneration(JackHerbein).

Mr. Guthrie was asked what his basis for believing that they were aware that this was going on and condoned or directed that this be done. Guthrie responded by stating: ,

From poing a test, from having a test handed to me that was greater than one, and showing it to the Shift Supervisor and  !

, he tells you to run another test.

~

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

Look for leaks. ,

j

- Mr. Guthrie went on to state that he believed the shift supervisors and j Mr. Floyd knew of this practice, but he did not provide any evidence which 1

indicated either Messrs. Logan or Herbein were involved in or aware of this j practice. M pages 43-45.

When Mr. Guthrie was informed that it appeared supervisors and operators were under a lot of pressure to keep things moving and keep the plant on the line, he stated, that was probably truc. When asked if he personally felt that he was under a lot'of pressure to interpret the technical specifications

! and the requirements more loosely, he responded by stating: "I probably felt l

personally that we weren't really adhering to the letter of the law." Sie pages 45 and 46.

l Despite the presst.re, Guthrie said that he was not pressured to manipulate -

test results. He said he never told any of the operators on his shift to j cheat on the test. There may have been occasions where things were done j inadvertently and he did not catch it in his review; however, they did not intentionally add hydrogen or water to influence the outcome of tests. It was pointed out to Mr. Guthrie that a very high percentage of tests performed on his shift and approved by him were questionable. Guthrie responded by i saying: "We may have been doing things that were manipulating it and not know that it was. But we did not do it with an intent to falsify the test." Seee i pages 46-49.

j Mr. Guthrie stated that his review of leak rate tests usually involved

looking at the end result and whether any water was added during the test.

In looking back at the tests now, he knows that there are things that occurred to invalidate tests, that he and his operators should have caught; however, they were just missed. If a test was acceptable, Guthrie would:

sign his name as approving the test; submit the surveillance paperwork; and put the time, date, and results on the control room status board. If a test ,

was determined to be invalid, it would be thrown away and not documented. i See pages 50-53.  !

1 I l

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

than 1 gpm. 5_ee e pages 53 and 54. ,

i The next portion of the interview concentrated on a detailed re' view of the i

leak rate tests approved by Mr. Guthrie. For each test, he was shown copies of the applicable surveillance test sheet, extracts from the CR0's Log and j a copy of the MUT level strip chart. See pages 54-80.

4 j *'

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

, saying that they thought the addition of hydrogen to the MUT would affect the leak rate, but Guthrie did not believe that either he or his CR0s were aware whether that was true prior to the accident. Sg,pages 55-57.

.With respect to problems with MUT level transmitters. Mr. Guthrie recalled

_ being aware that of at least one time period where one of the level transmitters was out-of-service and the Instrumentation & Control (!&C) personnel had marked it with an out-of-service sticker." Mr. Guthrie also i recalled providing instructions to his CR0s, that if one of the LTs was out-of-service, to ensure that the good one was used for leak rate tests.

i However Mr. Guthrie could not explain why some tests were run using the bad

! LT unless it was a mistake. jg, pages 58-61 With respect to accounted for water additions. Mr. Guthrie stated that prior

, to the accident, he was not aware of any significant difference between the the amount of water added as read off the totalizer and the amount indicated i by the rise in MUT level indication. He did not believe that his CR0s were i aware of this error and took advantage of that error in performing leak rate tests. jg,e,pages71-7g.

e i

In reviewing the overall results with Mr. Guthrie it was pointed out that i only six of the lg tests approved by him appeared to be valid testst the rest i ,

~ contained: hydrogen additions, feed a bleed operations, unstable plant -

conditions inaccurate and unreliable instrumentation providing input to the plant computer, or contained "underrecorded" water additions caused by MUT level instrumentation accuracies. Mr. Guthrie admitted that it appeared there were a considerable number of errors made. In some cases. Guthrie said it appears very sloppy and apparently very careless, but he did not believe anyone on his shift intentionally did anything to manipulate leak rate test results. jeg,pages80-84 In sumarizing Mr. Guthrie's testimony with him, he stated that he never approved a leak rate test knowing that it was legitimately in violation of the technical specifications. He also stated that while he never threw away test results over 1 gpm in order to hide them from the NRC. he was aware after. October 1978, that they were violating the technical specifications by i

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

l

13 Mr. Guthrie was asked if the operating philosophy at the time was to get rid of all the leak rate tests greater than 1 gpm in order to keep the plant i i

operating. Mr. Guthrie stated that he wouldn't necessarily say that, rather i they had a lot of things going on heading towards the accident such as many ,

plant evolutions and high leakage through the PORV and/or safety valves.

During the February /harch 1979 time-frame, when leak rate tests were very difficult to run, Guthrie believes the actions taken to resolve the problems were not very effective, jge,pages85and86 e When questioned about why such a high percentage of tests approved by him were invalid, Guthrie stated:

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

jee_pages90and91.

When Mr. Guthrie was asked to describe in his own words what his

] responsibilities were and what it meant for him to sign his name as approving

)4 a leak rate test, he stated:

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

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

i a hell of a lot of things going on. And we just weren't

given the input. What do ! look for in a surveillance test like that? Why isn't it written down in print? Do I have to find out by hindsight all the mistakes ! made on it?

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

4

! See pages 91 and 92.

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

i

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.. 4

-14 IV. Findings and Conclusions During the six months prior to the accident at TMI-2, while Mr. Guthrie i

served as a Shift Foreman, many of his actions, associated with~the performance and approval ,of RCS leak rate surveillance tests, violated approved plant procedures and technical specifications. Based upon the testimony of Mr. Guthrie and the three Control Room Operators on Shift "F,"

! coupled with the NRR technical evaluation of leak rate tests during this period, the following findings 6nd conclusions are drawn:

l 1. Although Surveillance Requirement 4.4.6.2 only required a leak rate test to be

operation, 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 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'l gpm were '

discarded, either directly by Mr. Guthrie or his CR0s.

t -

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

i and contrary to the licensee's stated corrective action in the LER i

78-62/1T, when test results indicated unidentified leakage in excess

of the limiting condition for operation (i.e.,1 gpm), Mr. Guthrie did i

not enter the action statement of Technical Specification 3.4.6.2,

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

that after October,1978, he was aware that action was required: "I i

probably felt personally that we wern't really adhering to the letter i of the law."

I i 4. When leak rate test results exceeded the limiting condition for

' operation of Technical Specification 3.4.6.2, Mr. Guthrie brought it to the attention of his Shift Supervisor. He was told to run another test and continue to look for leaks. According to Mr. Guthrie, it was a conscious decision by his Shift Supervisor not to enter the action statement of the technical specification. Mr. Guthrie stated that

- this practice may have been known and condoned by the Supervisor of -

Operations and possibly higher levels of management.

5. Although Mr. Guthrie advised the Shift Supervisor of unsatisfactory I.

! leak rate test results, contrary to TMI Administrative Procedure 1010,

" Technical Specification Surveillance Program." he did not complete

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

i t i

6. Contrary to TN! Administrative Procedure 1012. " Shift Relief and Log i

Entries " Mr. Guthrie was aware that CR0s were not logging the start I

time, stop time and the results of all leak rate surveillance tests in the Control Room Log.

1 l

l 7. Mr. Guthrie testified that he was aware of periodic problems with the MUT level transmitters and advised his CRos to perform tests using the stable level transmitter. Nevertheless, the NRR evaluation shows i

three of the tests approved by Mr. Guthrie were run with an erratic and unreliable level transmitter providing MUT level indication to the computer.

l l

=

l

Ii .

8. Mr. Guthrie testified that prior to the accident, he had heard that i adding hydrogen to the MUT could affect MUT level indication and consequently leak rate test results. However Guthrie also stated he 1

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

i g. Mr. Guthrie testified that he had no personal knowledge of any 1 operator adding water during the course of a leak rate test and not

, including the amount added in the calculation. The NRR evaluation

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

possible from the records available to differentiate between water or hydrogenforthisparticulartest.(seealsoitem8a'bove).

10. Mr. Guthrie testified that he was not aware of instrumentation -

inaccuracies between the batch controller and the MUT level indicators. Me did not believe his CR0s were aware of this problem

either and did not believe they would take advantage of such an , i inaccuracy during the performance of leak rate tests. The NRR evaluation shows three of the tests approved by Mr. Guthrie, involved -

water additions, where the amount of water logged in the CRO's Log and l 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 i

procedure was followed exactly as written. It is not possible to show (

whether Mr. Guthrie or his CRos knew of the instrument inaccuracy at ,

the time and used it to their advantage.

=

l In sunnar) Mr. Guthrie agrees in retrospect that many of his acticns

involving leak rate surve'11ance testing at TMI-2 violated approved plant l

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

l of problems with instrumentation and the procedure itself it appears

! Mr. Guthrie considered the test unreliable as far as representing true plant i leakage. When leakage above the limits of the technical specification were

brought to the attention of his Shift Supervisor, Mr. Guthrie was instructed 4 to run another test, and to continue to look for leaks. As a result of test problems and the lack of management concern for the test. he treated the test as an administrative requirement only.

While 12 of the 1g tests involving Mr. Guthrie during this period are ,

l considered invalid, and one additional test was not signed because it exceeded the limits of the technical specifications, there is insufficient i evidence to conclude that these tests were intentionally manipulated.

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

did not worry about establishing the proper steady-state conditions required i for the test and Mr. Guthrie's review only involved looking at the " bottom

! line" test results. Thus if a test result was greater than 1 gpm. it would

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

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

1 i

I i +

i I

i NOTE: This enclosure discusses information that is maintained in the NRC's i Privacy Act System of Records disseminated outside the NRC w'(NRC-16). This enclosure may not be i ithout coordination with NRR and the permission of the EDO. Internal access and distribution should be en a "need to know" basis. .

4 Enclosure 2 I. Backoround On June 4,1985, an interview was conducted with Mr. Carl L. Guthrie, a Senior Reactor Operator at Three Mile Island Nuclear Station, Unit 2 in order j

to determine Mr. Guthrie's understanding of his responsibilities for the safe operation of the plant and his comitment to those procedures and operating principles necessary to carry out those responsibilities. Participating in

the interview from the NRC were Mr. William T. Russell Acting Director,

_ Division of Human Factors Safety and Mr. Leonard Wiens, Senior Examiner. -

Operator Licensing Branch. Messrs. Smith B. Gephart and James Moeller and i Ms. Jane Penny, attorneys representing Mr. Guthrie, were also present during -

j the interview.

1

! Additional background information was obtained on Mr. Guthrie's current

! performance through interviews, conducted on May 17, 1985, with GPUN Site Operations Management and the NRC's Resident Inspectors for TMI-2. These interviews were conducted by Mr. William D. Travers Deputy Program Director.

TMI Program Office and Mr. Wiens. The personnel interviewed included:

l Name Position / Title 1 i Mr. Sandy Levin Site Operations Director, TMI-2

• l Mr. Ronald Cook Senior Resident Inspector, TMI-2 Mr. Thomas Moslak Resident Inspector. TMI-2 i .Section II contains a sumary of the interview with Mr. Guthrie, and the .

individuals listed above. Section !!! provides an overall conclusion regarding Mr. Guthrie's current performance.

II. Interview Sumary Mr. Guthrie appeared to be a cautious operator with a satisfactory knowledge i'

of operating procedures and administrative requirements in effect at THI-2.

He demonstrated excellent judgement when placed in hypothetical situations which did not have clearly correct solutions. In those areas in which he demonstrated some weaknesses, it was apparent that he would readily admit to such lack of knowledge and seek assistance from more knowledgeable operators.

t He expressed a comitment to strict compliance with procedures, and his responses during the interview indicated that all of his actions on shift would be based upon strict procedural compliance.

l

1

, r

)

l 111. Conclusions No information was obtained from the interviews with Mr. Guthrie, concerning Mr. Guthrie's current pe'rfory.ance which could be used as'a basis for revocation or modification of Mr. Guthrie's Senior Operator License.

The Senior Operator Upgrade Examination used to record the results of Mr.

Guthrie's interview is included as Attachment 2 and a copy of the questions '

asked of Mr. Guthrie, along with his responses are included as Attachments 3.

e e

G 8

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UNITED STATES IPhM5EW4mp?t

t ' '. 0 6' r -

N'? M;-: i

)

[ g NUCLEAR REGULATORY COEMISSION - I

. 5 B 90ASHips0 TON, D. C. 20046 August 20. 1985

(....+/ ,

l MEMORANDUM FOR: Harold R. Denton, Director '

l Office of Nuclear Reactor Regulation FRON: William T. Russell. Acting Director '

Division of Human Factors Safety. NRR

SUBJECT:

RESULTS OF JOINT 01/NRR INVESTIGATION AND EVALUATION OF THEODORE F. ILLJES

Reference:

1. MemorandumfromS.J.Chilk(SECY)to8.B. Hayes (OI) and W. J. Dircks (EDO) dated April 2,1984.

Subject:

Staff Requirements-Discussion of Pending Investigation-31

2. MemorandumfromH.R.Denton(NRR)toB.B. Hayes (01) dated May 3,, 1984.

Subject:

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

3. MemorandumfromW.T. Russell (DHFS)toH.R.Denton (NRR)datedJanuary 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. Theodore F.111jes, currently a licensed Senior Reactor Operator (SRO) at Three Mlle Island. Unit 2 assigned as a Shift Supervisor, and to provide a recomendation regarding whether his current SRO license should be revoked modified or suspended under 10 CFR 55.40 or other enforcement action taken under 10 CFR Part 55.50, due to his involvement in preaccident leak rate testing irregularities at TMI-2.

Background

As a result of a Cosmission meeting on March 23, 1984 NRR was directed by Reference 1 to review 0! investigative materials concerning falsification of l

reactor coolant system (RCS) leak rate tests at TMI-2 and refer back to 01 1

i i

NOTE: This memorandam and Enclosure 1 discuss information which is the subject of an ongoing 01 investigation. This memorandum and Enclosure 2 discuss inTormation that is maintained in the NRC's Privacy Act SystemofRecords(NRC-16). This memorandum and enclosures may not 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 on a "need to know" basis.

"~

f Y(~

• I Harold R. Denton August 20, 1985 those matters which required further investigation. The results of NRR's review was provided in Reference 2. The review determined that follow-up investigation by 01 and further evaluation by NRR was needed in the case of seven currently licensed operators. T. F. Illjes was one of these seven individuals. At a follow-up Commission meeting on May 23, 1984 NRR proposed joint 01/NRR investigations and evaluations of these individuals.

Subsequently, NRR issues letters to these individuals under 10 CFR 55.10(b) requesting additional information regarding current perfomance. Based upon the joint investigation into the individuals' past involvement in improper activities at TMI-2 and an evaluation of the individuals' subsequent perfomance, NRR would recomend what action, t f any, should be taken against the identified operators. As a result of some of the early interviews with these individuals and further technical analysis, Reference 3 recomended that three additional currently licensed operators also be interviewed. NRR issued similar letters to these individuals under 10 CFR 55.10(b). Of the ten individuals identified for investigation, seven are currently licensed on I TMI-2, two are licensed on Waterford 3 and one is licensed on San Onofre 2 and 3.

Past Involvement in TMI-2 Leak Rate Testing Irregularities On January 29, 1985, a join't 01/NRR interview of Theodore F. Illjes was held in the law offices of Killian & Gephart. Harrisburg, Pennsylvania. The interview was conducted in the presence of Mr. Illjes' attorneys. The purpose of the interview was to detemine Mr. Illjes' role, if any, in improper activities associated with RCS leak rate surveillance testing at TMI-2 prior to the accident on March 28, 1979. At that time, Mr. Illjes was a licensed Reactor Operator (RO) and served as a Control Room Operator (CRO) on Shift "B." A detailed evaluation of Mr. Illjes' interview and a sumary of the technical analysis of leak rate surveillance tests involving Mr. Illjes are provided in Enclosure 1 to this memorandum.

During the interview, many of Mr. Illjes' responses to general questions associated with leak rate surveillance test problems at TMI-2 were consistent with statements made to the NRC by other licensed operators; however, the majority of his responses regarding his personal involvement in or knowledge of leak rate test manipulation do not appear credible. Based upon the results of NRR's technical evaluation and Mr. Illjes' responses during the interview, the following sumary of findings and conclusions are drawn.

l '1. Although Surveillance Requirement 4.4.6.2 required RCS leak rate surveillance tests to be conducted 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, leak rate tests were run routinely run at least once per shift. Mr. Illjes stated that they "always had a leak rate on the computer." Sometimes, they ran three or four tests during the course of a shif t.

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2. Only satisfactory leak rate test results were logged in the CR0's Log.

Test results which exceeded the technical specification limit were not l logged. Note: These actions were contrary to TMI Administrative Procedure TUT 2, " Shift Relief and Log Entries," which required the title, number, start and completion time of all periodic tests required by the i

technical specifications (i.e., leak rate tests) to be logged in the CR0's Log.

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Harold R. Denton August 20, 1985

3. Because his shift ran so many tests, bad leak rate tests (i.e., net unidentified leakage greater than the technical specification limit of 1 gpm) were either thrown away directly by Mr. 111jes, or signed and placed on the Shift Foreman's desk or left on the computer for the next shift. Regardless of Illjes' original disposition of the test, any test indicating a value in excess of the technical specification limit, was eventually discarded. Note: This action was contrary to TMI-2 Technical SpecificationT.TU.1.d. " Record Retention," which required that records of surveillance activities required by the technical specifications be retained for a period of at least 5 years.

4. Mr. 111jes stated that operators questioned the validity of the computer program used for running leak rate tests. At times, test results could not be explained (e.g., different results for the same set of conditions). Overall, however, Illjes thought it was a useful tool. At times they were able to obtain a satisfactory test result the first time they ran the test and other times they might go an entire shift without

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obtaining an acceptable test result. When they were busy, they did hot take time to pursue what changes were taking place in the plant that might cause them to obtain unsatisfactory test results.

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5. Although the acceptance criteria of Surveillance Procedure 2301-3D1,

" Reactor Coolant System Inventory," required the operators to enter the action statement of Technical Specification 3.4.6.2, if unidentified leakage exceeded 1 gpm, Illjes stated that they did not interpret the requirement that way back then. He said, since the test was required only once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, they did not believe it was necessary to enter the action statement unless they exceeded the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> without obtaining a satisfactory test result. Note: The action statement required leakage to be reduced within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in cold shutdown within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.

6. Although Mr.111jes had initialed the routing sheet for Licensee Event Report (LER) 78-62/1T, he stated that he did not have a preaccident recall of the LER; therefore, the LER neither altered his interpretation of the technical specification nor did it change the way he performed the test or handled the test results. Note: Mr. 111jes statements are in conflict with the LER submitted to tiieTC on November 1,1978. The LER stated that the event was caused by misinterpretation of the requirements of the technical specifications and that appropriate personnel would be instructed on the requirements of applicable sections of the technical specifications and the requirement to imediately f invoke applicable action statements when the provisions of the limiting l conditions for operation were not met.

7. Mr. Illjes believed that as the date of the accident approached, it was harder to get good leak rate test results because of high identified leakage through either the PORY or code safety valves. He stated that although he was concerned with operating the plant with high identified leakage, he did not recomend that the plant be shutdown. At the time, i he did not believe that was his judgement to make. He discussed the leakage with his Shift Foreman and his Shift Supervisor and was told that "they were going to do something about it." Note: Identified leakage did not exceed the technical specificationMt of 10 gpm prior to the accident.

Harold R. Denton August 20, 1985

8. Mr. Illjes stated that prior to the accident, he was unaware that I hydrogen additions to the make-up tank (MUT) could affect MUT level indication and thus, favorably influence leak rate test results. Note:

Mr. Illjes' Shift Supervisor (Mr. Joseph Chwastyk) was deposed on April 24, 1984, as part of the TMI-1 leak rate investigation prepared for GPUN by Mr. Edwin Stier. During his deposition, Mr. Chwastyk stated that he first became aware of the effect of hydrogen on leak rate test results at TMI-2 in late 1978 and that he believed this phenomenon was brought to his attention by on& of his CR0s, specifically, Mr. Illjes.

9. Mr. Illjes testified that he never added hydrogen for the purpose of affecting leak rate test results and that he was not aware of this effect until sometime in 1980, after Hartman's allegations were made public. Note: Mr. Chwastyk stated that he conducted a test and personally observed the hydrogen effect on leak rate test results and implied the test was done when it was first brought to his attention..

Mr. Chwastyk also stated the he gave his' operators directions not to add hydrogen when they were doing leak rate tests until he could detemine what was causing the problem.

10. Mr. Illjes testified tilat he never intentionally added water for the purpose of affecting leak rate test results. If water was added during a test and not included in the calcufation, it was most likely caused by miscomunication between the operator perfoming the test and the operator on the panel who added the water. If water was added and the amount of water included in the leak rate calculation was less than amount indicated on the MUT strip chart, it was caused by instrumen-tation errors between the totalizer and the strip chart. He was not aware that the two instruments might read differently. He stated that he was also not aware that pressure changes in the MUT caused by the addition of water to the tank could be used to his advantage during the perfomance of a leak rate test.

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11. Mr. Illjes stated that since there were two level transmitters for MUT level indication (i.e., one feeding the strip chart and one providing input to the computer for leak rate calculations), it was possible to affect leak rate test results by switching between level transmitters during the test. However, he stated he did not become aware 'of this phenomenon until after the accident.

12. The technical analysis shows that between 09/30/78 and 03/28/79, 13 of the 18 tests (72%) involving Mr. Illjes included actions that were i

contrary to the precautions and limitations of Surveillance Procedure 2301-3D1. These actions included: unstable plant conditions; use of an unstable MUT level transmitter to provide input to the computer; water additions that were not properly included in the calculation, and hydrogen additions to the MUT. During the period where identified leakage was high (01/01/79 to 03/28/79), 7 out of 8 tests (88%)

involving Mr. Illjes included these procedural errors. These are the same type of " procedural errors" that other operators have admitted using to manipulate or influence the outcome of leak rate tests.

l l In sumary, while Mr. Illjes' now considers that some of his actions l regarding the conduct of leak rate tests were contrary to TMI-2 written procedures and technical specifications; he denies that he perfomed I

. . $aroldR.Denton #- August 20, .1985

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evolutions with the intent of influencing the outcome of leak rate test results. Based upon the weight of the available evidence, including the high number of invalid or questionable tests involving Mr. 111jes, and the testimony of Mr. Chwastyk. it appears that either Mr. Illjes was not truthful regarding his knowledge of or involvement in leak rate test manipulation or he was grossly negligent in that he ran many leak rate tests and would knowingly accept only test results less than the technical specification limit, regardless of_the evolutions in progress during the test.

Current Performance On January 31. 1985 NRR, conducted an interview and oral examination of Mr. Illjes. in order to determine his understanding of his responsibilities for the safe operation of the plant and his comitment to those procedures and operating principles necessary to carry out those responsibilities. In addition to the interview with Mr.111jes, an interview was coeducted with -

Mrs Illjes' supervisor on January 30, 1985. The supervisor interviewed was Mr. Sandy Levin the Site Operations Director. Enclosure 2 to this memorandu.m contains the evaluation of Mr.111jes' current performance as well as the Senior Operator Upgrade Examination Report used to record the results of his interview and a copy of the questions asked to Mr. 111jes during his -

interview.

Throughout the interview Mr.111jes appeared to be" a very conscientious, dedicated operator. Me seemed to be sincerely comitted to operating the plant safely and in accordance with all procedures and regulations. He demonstrated a very cautious measured approach to plant operations. He also demonstrated a thorough knowledge of procedures and technical specifications and the ability to use them. When placed in postulated situations not covered by procedures, he displayed good judgement in his choice of actions and was quick to censult with management and the NRC to resolve problems.

His highest priority appeared to be ensuring that all evolutions conducted on his shift were,done properly and in accordance with approved procedures.

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In susmary no information was obtained from the interviews with Mr.111jes which could be used as a basis for revocation or modification of Mr.111.fes' Senior Operator's License.

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Conclusiens During the period Mr.111jes was Itcensed as a Control Room Operator at TMI-2 prior to the accident, 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 Specification. These

- actions included: the throwing away of leak rate test results in excess of the technical specification limit; not logging unsatisfactory test results; and on occasion not pursuing what changes were taking place in the plant that might be causing them to obtain unsatisfcetory test results. However.

he denies that he was involved in other actions including leak rate test manipulation or falsification or knowledge that such activities were going on around him. The weight of available evidence. including statements by his .

fomer Shift Supervisor (Mr. Chwastyk) and the technical analysis, strongly suggests that Mr.111jes was either not truthful in answering questions '

regarding his role in or knowledge of leak rate test manipulation or he was grossly negligent in performing leak rate tests. -

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Based upon the tes'timony of the majority of other CRO's and Shift Yoremen " interviewed to date. it is clear that management's standards for procedural compliance were lax and ,

permissive. In my opinion this was created through negligence on the part of management. Lack of operator respect for the leak rate test procedure coupled with management's failure to correct test procedure problems and to instill high standards for procedural compliance led to conditions that  ;

motivated some operators to falsify leak rate test results.

I believe Mr.111jes does understand his duties and responsibilities for conducting safe operations at TMI-2 and that he is comitted to following approved procedures and principles necessary to -

carry out those responsibilities.

In sumary, while I suspect the accuracy of some of Mr.111jes' statements regarding leak rate testing irregularities. I am unable to prove that he lied. I do believe that he may have been involved in or had knowledge of l 1eak rate test manipulation. lx

! recomend that enforceinent action not be taken against Mr.111jes at this time. Rather. I

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recomend that he be placed in a probationary status until the expiration t date of his current SRO license (April 2. 1986). The renewal of Mr.111jes' license at that time would be dependent upon satisfactory performance during the probationary period. Origine.I syned 37 .

WILLInt ;. .re!w.,t William T. Russell. Acting Director Division of Human Factors Safety n m r. nr wort.>r o.w.n, n o .,L . u.-

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,3, NOTE: This enclosure discusses infonnation which is the subject of an ongoing 01 investigation. This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO or the Director. 01. Internal access and distribution should be on a "need to know" basis. .

Enclosure 1 PASTINVOLVEMENTINTMI-2LEAKRATETESTINGIRREGULARITIM I. Background On January a joint Office of Investigations (01)/ Office of Nuclear Reactor Regulation29,1985(NRR) interview of Theodore F.111jes was held in the la offices of Killian & Gephart Harrisburg, Pennsylvania. The purpose of the

- ' interview was to determine Mr.111jes' role, if any, in improper activities associated with reactor coolant system (RCS) leak rate surveillance testing at Three Mile Island, Unit 2 (TMI-2) prior to the accident on March 28, 1979.

Present during the interview representing the NRC were: R. Keith Christopher.

Director. Office of Investigations, Region I; William T. Russell, Deputy Director, Division of Human Factors Safety; and Robert A. Capra, Senior Program Manager, Staff of the Executive Director for Operations.

Representing Mr.111jes at the interview were his personal attorneys. Mr.

Smith B. Gephart of the law firm Killian & Gephart Harrisburg, Pennsylvania and Mr. Harry H. Voigt of the law fira LeBoeuf Lamb. Leiby and MacRae, Washington, D.C. A copy of the transcript associated with this interview is provided as Attachment 1 to this enclosure.

Mr.111jes is currently employed by General Public Utilities Nuclear Corporation (GPUN) as a Shift Supervisor and holds a Senior Reactor -

Operator's (SR0) license for TMI-2. Prior to joining Metropolitan Edison Company (Met-Ed) in January 1971. Mr.111jes served for seven years in the

, U.S. Navy's nuclear submarine program. His first few months with Met-Ed were spent working at Crawford Station. He was then transferred to Three Mile Island and worked as an Auxiliary Operator (AO) at TMI-1. He remained in that position until he was placed in the cold licensing operator training group for Control Room Operators (CR0s) at TMI-2. He received his Reactor l Operator's (RO) Itcense in October 1977 and served as a CR0 at TMI-2 until late 1979, when he was promoted to Radwaste Shift Foreman. He later served as a Shift Foreman in the Control Room and in 1982 was promoted to his present position of Shift Supervisor. Mr.111jes received his initial SRO license in April 1980.

The interview with Mr.111jes concentrated on the period September 30, 1978 through March 28, 1979. During this time period, he served as a CR0 at TMI-2 assigned to Shift "B." At that time, Shift "B" consisted of the following licensed individuals:

SHIFT "B" Shift Supervisor SRO Joe Chwastyk Shift Foreman SRO Bill Conaway CR0 RO John Kidwell CR0 R0 Ted 111jes CR0 (in training) --

Chuck Mell

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2 A sumary of the technical analysis of the leak rate tests involving Mr.

111jes is provided in Section II of this enclosure. A sumary of the interview with Mr.111jes is provided in Section III. The sumary of interview includes citations to the page numbers of the transcript from which the sumarized infomation was extracted. Overall conclusions regarding Mr.

111jes' involvement in improper activities associated with THI-2 leak rate surveillance testing are presented in Section IV of this enclosure.

i II. Sumary of the Technical Analysis In late 1983 and early 1984, a technical analysis of the leak rate surveillance tests perfomed during the last six months of operation of TMI-2 was performed by the NRC. This analysis was done as technical support to the Department of Justice (DOJ) in its criminal proceeding against Met-Ed. The results of this analysis were used in questioning Mr.111jes ,during his interview. However, based upon information obtained during interviews with former TMI-2 operators, a reevaluation was performed during the sumer of

_ 1985. The sumary of technical analysis provided in this section relies on the updated 1985 analysis. The major differences between the two analyses, with respect to Mr. Illjes' tests, will be explained at the end of this section. While the complete 1985 evaluation of leak rate tests at TMI-2 is provided as Attachment 2 to this enclosure, a summary of the conclusions regarding Mr.111jes' tests is provided here to help the reader understand the basis for the questions posed to him during his interview and the basis for the conclusions shown in Section IV.

The test records show that of the 161 leak rate surveillance tests retained by the licensee during the period under investigation. Mr.111jes was involved in 18 of these tests. During the 18 tests, he was either the individual who performed the surveillance test or was the operator on watch (i.e., the panel operator) who signed the CRO's Log for the period during .

which the test was conducted. The table below shows a breakdown of the overall conclusions regarding Mr. 111jes' tests.

Breakdown of Leak Rate Tests Involving T.F. Ill.ies Evaluation Category Number of Tests Total number of tests on fi1e...................................... 18 Tests with no apparent problems.................................... 5 Tests involving unstable plant conditions.. ...... .. .... ... ... .. ... . 3 Tests involving the use of an unsS.able make-up tank level transmitter as input to the platt computer....................... 6 Water additions that were not included in the calculation.......... '

3 Water additions where the amount of water added was only i

partially included in the calculation............................ 1 Ifydrogen additions to thr.make-up tank during the test............. 3 Hydrogen or water additic6s during the test (unable to differentiate).........j..........................................I hote: Ferr tes.ts fall inko more than one evaluation category.

Test 28 contains both unstable plant conditions and a water I

i. addition that was not included in the calculation.

Test 31 contains both unstable plant conditions and was run with the make-up tank (MUT) level transmitter providing input to the computer reading 13" lower than the level transmitter feeding the MUT level strip chart recorder.

Test 56 contains both a possible water addition that was not included in the calculation and was run with the unstable make-up tank level transmitter (LT-1) providing input to the computer.

Test 69 contains a possible hydrogen addition and was run with unstable LT-1 providing input to the computer. .

As can be seen from the table above, only five of the 18 tests involving Mr.

111jes during the last six months of operation at TMI-2 appear to be conducted in accordance with the requirements and precautions of the surveillance procedure governing the conduct of leak rate tests (SP 2301-3D1). The remaining 13 tests involve actions that violate the limits and precautions of the procedure, thus, yielding questionable or invalid results. For some tests, actions may have been taken in an attempt to manipulate or influence the outcome of the leak rate test results. The basis for our evaluation of each test is presented below. ~

_ The five tests that appear to have been conducted in accordance the surveillance procedure are tests #11 (10/15/78), #22 (10/24/78), #32 (11/02/78), #46 (12/04/78) and #117 (02/13/79).

Threetests,#9(10/13/78),#28(10/29/78)and#31(10/31/78), were performed when the plant was not in a steady state condition. SP 2301-301 directs that the test be performed once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady state operation when in Modes 1 through 4. The procedure also cautions the operator to maintain the RCS and make-up system 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 and the operator should avoid additions or removal of water from the RCS and make-up system during the test.

For the most accurate determination of the RCS leak rate, the initial and final conditions of reactor power, RCS temperature, pressure and pressurizer level should be identical. Test #9 was conducted during a secondary plant' startup. The spray valve (plant wasTave RC-V-1). experiencing problems with varied approximately 4.5'F the during Tave controller and the test. Test results showed net unidentified leak rate as -8.5 gpm. Test #28 was also conducted during a secondary plant startup. Large oscillations occurred during the test in Tave, pressurizer level and make-up tank (MUT) level indication. In addition, a 330 gal water addition was made to the MUT, logged in CRO's Log, but not included in the leak rate calculation. Test #31 was conducted in Mode 3 (hot standby) with primary plant testing in progress.

Large changes in pressurizer level (+10'5") and MUT (-7") occurred during the test. While these tests do not represent examples of intentional manipulation, they do represent examples of tests that may have been retained because the results were less than technical specification limit even though stable plant conditions did not exist. These tests are considered invalid.

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 level recorder strip chart 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

. switch is positioned to LT-1, the strip chart recorder would be driven by the cutput of LT-1 and LT-2 would provide autcmatic input to the plant cc:puter i

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• 4 for leak rate test calculations. When the selector switch was changed to LT-2, the strip chart recorder would be driven by LT-2 and the computer would receive its MUT level indication from LT-1.

Between October 30 and November 6,1978, operators experienced problems with both level transmitters. At various times during this period the level transmitters were reading radically different levels in the MUT and both were taken out of service for maintenance work and recalibration. During this period Mr.111jes was involved in leak rate test #31 (10/31/78). This test was not only performed during unstable plant conditions but the level transmitter providing input to the plant computer was reading approximately 13" lower than the level transmitter driving the strip chart recorder.

Beginning December 1, 1978 and continuing through January 11, 1979 the output of LT-1 became 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 durin i

were performed with the stable level transmitter (LT-2)gproviding this period only'16 input to the computer during the test. During this period, Mr.111jes was involved in 6 tests, 5 of which used unstable LT-1 as input to the computer. These 6 tests are: #46(12/04/78),#47(12/05/78),#56(12/11/78),#69(12/20/78),

1. 90 (01/07/79) and #91 (01/08/79). .

Test #46 was the only test involving Mr.111jes that used stable LT-2 as input to the computer during this period. The test was started on Mr.

111jes' shift and was completed by Shift "D."

Approximately five minutes before the beginning of leak rate test #47 the level transmitter was shifted such that LT-1 would provide input to the computer. The data shows a significant difference between the output of LT-1 and LT-2 during the test. This was the same shift that the Shift Foreman (Bill Conaway) submitted a work request to repair LT-1 due to level oscillations.

During leak rate test #56, MUT level should have decreased approximately 2";

however, because LT-1 was used, the test indicates MUT level actually increased 2". It is also possible that a small amount of water (60 gal) may have been added during this test. There is no log entry for a water additica and no water addition is included in the calculation. During leak rate test

1. 69, final MUT level is higher than initial level. From the trace on the strip chart it appears that either hydrogen was added approximately ten minutes before the end of the test or the level transmitters were switched one or more times near the end or the test. The net effect during the one hour test was approximately +3.5" or 100 gal.

When test #90 was conducted, the slope of the MUT was approximately -3"/hr.

indicating substantial gross leakage. However, because of the use of LT-1 the net unidentified leakage calculated by the computer was as .22 gpm.

The following day test #91 was conducted in a similar manner. Instead of MUT level decreasing 3" during the test, the level seen by the computer increased 1.2", again giving a negative valve for net unidentified leakage.

5 During the entire period of time LT-1 wat essentially out of comission, all shifts, including Mr. Illjes' shift, continued to run leak rate tests (34 out of 50) with LT-1 providing MUT level indication to the computer resulting in a meaningless calculation of unidentified reactor coolant system leak rate which could not demonstrate conformance with the technical specification  :

limit of 1 gpm. .

Threetests,#28(10/29/78),#56(12/11/78)and#115(02/12/79) included possible water additions that were not accounted for in the leak rate test calculation. Test #29, as discussed above, was performed during a period of unstable plant conditions; however, the test also included a water addition of 330 gal that was not included in the calculation. The water addition is logged in the CR0's Log. Test #56, also discussed above, possibly contains a small water addition of approximately 60 gal. There is no log entry that -

water was added. If water was not added during the test, the test is still considered invalid because of the use of unstable LT-1. Test'#115 contains a ISO gal water addition near the beginning of the test. The water addition is neither logged in the CRO's nor taken into account in the test calculation.

Also during this test, it appears that the reactor coolant drain tank (RCOT) was pumped down. This evolution is also not logged or taken into account in the calculation.

There is also one test, #147 (03/14/79) where the amount of water added according the MUT strip chart is significantly different from the amount J logged in the CR0's log. The MUT strip chart shows water additions of 390 gal and 210 gal at 1235 and 1250, respectively. The CRO's Log shows water additions of 300 gal and 200 gal at 1230 and 1250, respectively. A 500 gal addition was included in the calculation; however, it was included in the wrong step, i.e., water deletions not water additions. Because of possible instrument inaccuracies between the totalizer (digital readout of amount of water added) and the MUT strip chart recorder, it is not possible to determine whether this' test was intentional under-recorded or whether Mr. ~

111jes was a victim of instrument error. Nevertheless, because the water addition was not entered into the computer properly, the test is invalid.

One of the possible mechanisms for MUT level instrumet inaccuracies during water additions is discussed below.

As discussed in other reports involving TMI-2 leak rate test investigations, the addition of hydrogen to the MUT theoretically should not alter MUT level indication. 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 leg of the level transmitters. Under this condition, 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 (e.g., the calculated leak rate would be less than the actual leak rate). Also because adding water to the MUT compresses the hydrogen gas in the top of the MUT water additions to the MUT shortly before the computer obtained its final data set would thus have the same effect as a hydrogen addition.

.s.

Three tests, #69 (12/20/78), #123 (02/17/79) and #124 02/19/79) involving Mr.

111jes appear to include hydrogen additions during the test. Test #69 exhibits characteristics similar to other known hydrogen additions; however, because this test also involved the possible switching of level transmitters between LT-1 and LT-2, a firm conclusion can not be drawn. There is no log entry indicating a hydrogen addition. Nevertheless, an evolution was performed approximately 10 minutes before the end of the test which affected HUT level +3.5". Test #123 contained a hydrogen addition shortly before the and of the test. While no log entry appears in the CR0's Log, the AO's log indicates hydrogen was added approximately 11 minutes before the end of the test. MUT level was affected approximately +1" to +2". Test #124 also exhibits characteristics similar to other known hydrogen additions. The hydrogen appears to have been added approximately 1 minute before the end of the test. No log entry was made. Again MUT level indication was affected approximately +1" to +2".

Finally, Test #125(02/19/79), which was started by Mr.111jes shift only 35

_ minutes after completing test #124, also contains a possible hydrogen addition. While the characteristics are similar to other hydrogen additions, the MUT level remains higher following the transitory response seen with other hydrogen additions. This characteristic could also represent a small water addition of approximately 3.0 gal. .Thus, this test was evaluated as either a hydrogen addition or water addition. .

As discussed in the beginning of this section, when Mr. 111jes was interviewed by O!/NRR in January 1985, he was questioned prior to NRR's reevaluation of the 161 leak rate tests. The differences between the "sumary of tests" discussed with Mr.111jes and the revised analysis include the following:

1. Two tests were added to the list: #9(unstableplantconditions)andf22 (no apparent problems). ,

2. The significance of LT-1 during its unstable period has now been highlighted. Thus, tests #47, 90 and 91 were reclassified from "no

. water / hydrogen additions" to " unstable LT-1." Tests #56 and #69 were run on unstable LT-1 but also contained a possible water and hydrogen addition, respectively'and thus were already considered invalid. Mr.

111jes' personal knowledge regarding level transmitter problems was not discussed with him during the interview.

3. Test #31 was reclassified from "no apparent problems" to " unstable plant conditions."

4. Test #46 was reclassified from " water addition" to "no apparent ,

problems and LT problems."

5. Test #125 was reclassified from " water addition" to " water or hydrogen addition." .

In sumary, the technical analysis shows that between 09/30/78 and 03/28/79, 13 of the 18 tests (72%) involving Mr.111jes included actions that were contrary to the precautions and limitations of Surveillance Procedure 2301-301. These actions included: unstable plant conditions; use of an unstable MUT level transmitter to provide input to the computer; water additions that were not properly included in the calculation, and hydrogen

, additions to the MUT. During the period where identified leakage was high (01/01/79 to 03/28/79), 7 out of 8 tests (88%) involving Mr.111jes included

7 these procedural errors. Based upon the high number of questionable or invalid tests, it appears that the tests were accepted as valid as long as the result was less than the technical specification limit, regardless of the evolutions in progress during the test. For some of these tests, evolutions were identified which other operators admitted utilizing to manipulate or influence the test results. ,

III. Interview Summary During the period under investigation September 30, 1978 through March 28, 1 1979 Mr.111jes indicated that he was assigned primarily to "B" Shift. The licensed members of his shift included: Shift Supervisor, Joe Chwastyk; Shift 1

Foreman, Bill Conaway; and Control Room Operators (CR0s), John Kidwell and himself. In addition Charles Mell was an unlicensed CRO-in-training assigned to their shift. je_epages5-6. ,

111jes stated that he had a close working relationship with his Shift Foreman. Both his Shift Foreman and his Shift Supervisor were knowledgeable about operations that occurred during the shift, although Conaway, being in Unit 2 more that Chwestyk, was a little more familiar with the details.

111jes had little day-to-day contact with management personnel such as the Supervisor of Operations (J. Floyd), the TMI-2 Superintendent (J. Logan) or the Station Manage'r (G. Miller). 53e,pages 6-7.,

In describing how his shift was organized 111jes stated, that one man would have the panel. The panel operator would be responsible for controlling the plant, maintaining the CRO's Log, and directing evolutions perfomed by the Auxiliary Operators (A0s). One CR0 would take charge of perfoming the

" switching and tagging" duties and the third CR0 would usually take care of the paperwork. They would normally rotate positions each day. Se_e pages 10-11. .

The panel operator was the individual who normally would make any water additions to the reactor coolant system (RCS) or hydrogen additions to the MllT although, the panel operator could ask either of the other CR0s to perform the evolution, if he were busy. See page 12.

NOTE: The CR0 performing the leak rate surveillance test was normally one of the CRO: who did not have the panel.

After reviewing copies of TMI-2 Technical Specification 3/4.4.6.2, " Reactor Coolant System Operational Leakage," and Surveillance Procedure 2301-3D1,

" Reactor Coolant System Inventory," 111jes stated that the Technical Specifications required them to perform a RCS leak rate test at least once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />; however, they normally performed the test every shift. He stated that they "always had a leak rate on the computer." Sometimes, they ran three or four tests during the course of a shift. See pages 8, 10, 13.

NOTE: Surveillance Procedure 2301-3D1 was used at TMI-2 to demonstrate compliance with Technical Specification 3.4.6.2. The technical specification required, among other limits, that RCS unidentified leakage be limited to 1 spm. Technical Specification 4.4.6.2 required RCS leakages to be demonstrated to be within limits by performance of a RCS water inventory balance (leak

, rate test) at least once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady state operation.

N -

Because his shift ran so many tests, all results were not retained. Some were thrown away, some were put on the Shift Foreman's desk, and some were left on the computer for the next shift. When unacceptable test results were obtained (i.e., unidentified leakage in excess of Lgpm) 111jes said he would try to determine the cause of the problem. In some cases. it was discovered that the panel operator may have added water during the test or pumpeddownthereactorcoolantdraintank(RCDT)andtheseevolutionshad not been taken into consideration in the computer calculation. See pages 13-14. I i

i NOTE: The surveillance procedure cautioned the operators to avoid such operations during the performance of leak rate tests; however if changes to RCS inventory had to be made during the performance of a test, they had to be accounted for by inputting the data into the plant computer before the leak rate calculation wa's obtained.

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Mr. Illjes could not recall the rationale he used for determining which tests he would retain and which tests he would throw away. Although he remembered

throwing away test results that were " ridiculous." he thought that he signed most of the tests and put them on the Shift Foreman's desk even if the i

. results were unacceptable. He did not believe tiera l was a consistent practice on their shift for retaining or throwing away test results. See pages 14-17.

NOTE: Technical Specification 6.10.1.d required that records of surveillance activities required by the technical specifications (i.e.,leakratesurveillancetests) l be retained for a period of five years.

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I When asked if he had faith in the results of the computer program for l performing the surveillance test. Illjes said that the operators questioned the program because sometimes test results could not be explained (e.g..

obtaining different results for the same set of conditions). Overall, however, he thought it was a useful tool. He said there were times when they were busy and they did not take the time to pursue what changes were taking place in the plant that might cause them to obtain an unsatisfactory test result. Occasionally they were able to get a satisfactory test result the first time they ran the test and other times they might go an entire shift without obtaining an acceptable test result. See pages 17-19.

Mr.111jes stated that he was not aware of the requirement in Administrative Procedure 1012. " Shift Relief and Log Entries." to log the start and stop time for all surveillance tests. He recalled logging the completion time in the CRO's Log for test results that were satisfactory; however, unsatisfactory results were not logged. He said that no one ever directed

, him not to log test results as an attempt to hide the fact they were having to run so many tests. See,pages 1g-20.

NOTE: Section 3.3.17 of AP-1012 required that the title, number, start and completion time of all periodic tests required

, by the technical specifications (i.e., leak rate tests) be logged in the CRO's Log.

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. .g-Although the acceptance criteria of Surveillance Procedure 2301-3D1 required the operators to enter the action statement of Technical Specification 3.4.6.2 if unidentified leakage exceeded 1 gpm. Illjes said that they did not interpret the requirement that way back then. He said, since the surveillance test only had to be run once ever 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, they did not believe it was necessary to enter the action statement unless they exceeded the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> without obtaining a satisfactory test result. Illjes stated that their interpretation would be different today. "but at the time, unfortunately, that was our interpretation." jee pages 21-22.

NOTE: The action statement of Technical Specification 3.4.6.2 stated: "With any Reactor Coolant System leakage greater than any one of the above limits, excluding PRESSURE BOUNDARY LEAKAGE. reduce the leakage rate to within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least HOT STANDBY within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUTDOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />."

_. Mr. Illjes was asked to review a copy of Licensee Event Report (LER) 78-62/1T. The LER described an event which occurred in October 1978 in which i

an NRC inspector found several leak rate surveillance tests lying in the Control Room which indicated the unidentified leak rate was in excess of the requirements of the technical specifications. It was pointed out to Mr.

Illjes that the narrative section of the LER stated the event was caused by a misinterpretation of the requirements of the technical specifications and that appropriate personnel would be instructed on the requirements of the i technical specifications (i.e., the requirement to immediately invoke the action statement when the provisions of the limiting condition for operation are not met). Although Mr. Illjes had initialed the routing sheet for the LER. he stated that he did not have a preaccident recollection of the incident and did not recall any receiving any specific instruction on the l proper interpretation of the technical specifications. See pages 23-28. .

Mr. Illjes stated that following this incident he did not receive instructions from anyone to ensure that unacceptable leak rate test results were thrown away and not left lying around where the NRC could find them.

Mr. Illjes was infomed that on April 24, 1984, his Shift Supervisor (Mr.

Chwastyk) testified that he did provide direction to his shift to throw away invalid leak rate tests. Mr. Illjes said that while he did recall throwing test results away, he did not recall doing that as a result of directions from Mr. Chwastyk and did not remember any heightened sensitivity to ensuring invalid tests were thrown away. See pages 28-30 and Chwastyk Dep. at pages 24-25.

NOTE: Mr. Chwastyk was deposed as part of the TMI-1 leak rate investigation prepared for GPUN by Mr. Edwin H. Stier. Mr. Chwastyk's deposition appears as

" Witness Statement C" of Appendix C to the Main Report. Excerpts of Mr. Chwastyk's April 24, 1984 deposition are included as Attachment 3 to this Enclosure.

. Illjes did not believe is was necessary to rely on leak rate test results to determine if the plant was leaking. He stated that if there was a problem.

. . the operators could tell by looking at the change in slope of the MUT level recorder. The slope would change for any significant leakage. jeepages 30-31.

Mr.111jes believed that as the date of the accident approached, it was harder to get good leak rate test results because of high identified leakage through either the PORV or code safety valves. He recalled that one of the i v.alves was leaking but did not know which valve was causing the problem. He l recalled tail pipe temperatures downstream of the valves being higher than normal and that they were planning on changing out one of the relief valves during the next scheduled outage. See pages 31-33.

NOTE: cification limit for identified Whilethetechnicalsfwas.notexceeded,thehighleak leakage (i.e.,10gpm .

rate and errors in the procedure made it more difficult

, to obtain a test result for unidentified leakage within 197 Mr.111jes stated that he was concerned with operating the plant with high' identified leakage; however, he did not recommend that the plant be shutdown.

He said at the time, that was not his judgement to make. He believed he discussed the problem with his Shift Foreman and his Shift Supervisor. He said he knew they had a problem, but he was told,they were going to do something about it. 111jes said, "maybe that was justification enough for me." See pages 33-35.

In discussing the effect of hydrogen on leak rate test results Mr.111jes stated that they were required to sr.intain a certain hydrogen overpressure on

the MUT. When hydrogen pressure dropped to the low and of the operating band, they would add hydrogen. 111jes stated that he knows now that adding hydrogen to the MUT could influence MUT level indication and consequently leak rate test results. However, he said that he was not aware of this -

phenomenon prior to the accident. It was pointed out that several operators have testified that the hydrogen effect was cosmon knowledge on all shifts.

. Nevertheless,111jes maintained his position that he was not aware of this i until after the accident. See pages 37-38.

It was pointed out to Mr.111jes, that his Shift Supervisor (Joe Chwastyk) testified on April 24, 1g84 that he first became aware of the effect of hydrogen on leak rate test results in late 1978 and that he believed this phenomenon was brought to his attention by Ted 111jes. Chwestyk said he rersonally observed the phenomenon, did not understand why it was happening and contacted Instrumentation & Control (ISC) personnel to investigate the matter. Chwestyk also stated that he gave his operators directions not to add hydrogen when they were performing a leak rate test until he could determine what what was causing the problem. In spite of Mr. Chwastyk's testimony, Mr.111jes stated, that he did recall bringing this matter to Chwastyk's attention and he did not remember running an experiment to show Chwastyk the phenomenon. He said that if he would have done something like that, he would remember it. See pages 39-40 and Chwastyk Dep. pages 27-35.

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NOTE: While Chwastyk stated that he conducted a test and personally observed the hydrogen effect on leak rate test i results and implied the test was done when it was first '

, brought to his attention, Chwastyk did not specifically  !

state that Mr.111jes was involved in the experiment. l As discussed in Section II of this report, it is believed

, that hydrogen was added during leak rate test #69. This test was performed by Mr. Illjes on December 20, 1978.

This time frame is consistent with Mr. Chwastyk's testimony that he was made aware of the hydrogen effect in late 1978.

I Mr.111jes testified th'at he never added hydrogen for the purpose of influencing leak rate test results and that he was not aware of this effect' until sometime in 1980, after Hartman's allegations were made public. See pages 41-42. .

At this point in the interview, Mr.111jes was provided a pat:kage of material '

_ associated with leak rate tests he was involved in during the period being l investigated. The package included a summary sheet, leak rate surveillance

. test data sheets, extracts from the CR0's Log, and copies of the strip chart ,

recorder trace for MUT level indication. After explaining the material in '

detail, Mr. Illjes was allowed to review the package in private with his

attorney. See pages 42-46.

i Following his review of the leak rate test material, five of the tests were discussed with Mr.111jes. These tests showed examples of two water additions where the amount of water added was either not included or only partially included in the test calculation and three cases where hydrogen was added to the MUT during the course of the leak rate test. See pages 46-64 In discussing water add'itions during leak rate tests Mr.111jes was asked.if he was aware that the amount of water added in gallons, as read off the totalizer, could be different from the amount of water added, as shown by the

change in MUT level indication and that that difference could be used to influence the leak rate test results. If water were added during a leak rate test,111jes said he would use the amount of water indicated on the totalizer as input to the computer as opposed to using the amount indicated on the MUT strip chart. Mr. 111jes stated that he was aware that they had experienced i

some problems with water in the loop seal of the MUT level transmitters; however, he said he was not aware that pressure changes in the MUT caused by the addition of water to the tank could be used to his advantage during the performance of a leak rate test. Sg,pages 59-64.

During the review of Mr.111jes' leak rate tests, he did not agree with all of the conclusions of the technical evaluation. Nevertheless, sufficient i questionable evolutions occurred during these tests that caused Mr.111jes to state that in operations today, he would pay a lot more attention to ensuring j that the individual performing the leak rate test and the individual on the l panel were aware of what each other was doing. According to Mr.111jes, if

, water and/or hydrogen were added during the course of a leak rate test and not properly included in the calculation, it was not done intentionally to

. manipulate the outcome of the test. See page 58.

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It was pointed out to Mr. Illjes that based upon Chwastyk's testimony, the testimony of several fomer operators who admitted their involvement in activities that influenced the outcome of leak rate tests, and the technical evaluation of all leak rate tests performed at TMI-2, it was difficult to understand how he could not have been aware of what was going on around him.

Mr. Illjes stated: "You can take it for what it is worth. You know, it is

, going on six years. I am saying I didn't intentionally manipulate a leak rate. I can say that. It is safe in my mind that I didn't do something to conscicusly cheat on a leak rate." 111jes also reiterated the fact that he was not aware of any operator manipulating leak rate test results until after the accident. See pages 65-66. ,

1 Mr.111jes was asked if he could provide any additional information regarding l 1eak rate testing practices that he may have had knowledge about but was not '

questioned about during the interview. Mr.111jes stated that since there were two level transmitters for MUT level indication (i.e., one feeding the strip chart and the other feeding the computer), it was possible to affect-leak rate test results by switching between level transmitters during the test. Illjes stated, however, he was also not aware of this phenomenon until after the accident. See pages 76-77.

IV. Conclusions - -

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While many of Mr. Illjes' responses to questions associated with leak rate surveillance test problems at TMI-2 were consistent with statements made to the NRC by other licensed operators, the majority of his responses regarding his personal involvement in or knowledge of leak rate test manipulation do not appear credible. Based upon the results of NRR's technical evaluation and Mr. Illjes' responses during the interview, the following conclusions are drawn. ,

1. Although Surveillance Requirement 4.4.6.2 required leak rate surveillance tests to be conducted 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, leak rate tests were run routinely run at least once per shift. Mr.111jes stated that they "always had a leak rate on the computer." Sometimes, they ran three or four tests during the course of a shift.

2. Only satisfactory leak rate test results were logged in the CRO's Log.

Test results which exceeded the technical specification limit were not logged. Note: These actions were contrary to TMI Administrative Procedure TOTZ, " Shift Relief and Log Entries," which required the title, number, start and completion time of all periodic tests required by the technical specifications (i.e., leak rate tests) to be logged in the -

CRO's Log.

3. Because his shift ran so many tests, bad leak rate tests (i.e., net unidentified leakage greater than the technical specification limit of 1 gpm) were either thrown away directly by Mr.111jes, or signed and placed on the Shift Foreman's desk or left on the computer for the next shift. Regardless of 111jes original disposition of the test, any test indicating a value in excess of the technical specification limit, was eventually discarded. Note: This action was contrary to TMI-2 Technical SpecificationU.I.d, " Record Retention," which required that records of surveillance activities required by the technical specifications be retained for a period of at least 5 years.

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,33, 4 Mr. Illjes stated that operators questioned the validity of the computer program used for running leak rate tests since test results could not be explained (e.g., different results for the same set of conditions).

Overall, however, he thought it was a useful tool. At times they were able to obtain a satisfactory test result the first time they ran the test and other times they might go an entire shift without obtaining an acceptable test result. When they were busy, they did not take time to '

pursue what changes were taking place in the plant that might cause them i

to obtain unsatisfactory test results.

5. Although the acceptance criteria of Surveillance Procedure 2301-3DI,

" Reactor Coolant System Inventory," required the operators to enter the

' action statement of Technical Specification 3.4.6.2, if unidentified leakage exceeded 1 gpm, Illjes stated that they did not interpret the requirement that way back then. He said, since the test was required only once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, they did not believe it was nec.essary to enter the action statement unless they exceeded the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> without obtaining a satisfactory test result. Note: The action statement required leakage to be reduced within TTiiiits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in cold shutdown within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.

6. Although Mr.111jes had initialed the routing sheet for LER 78-62/17, he stated that he did not have a preaccident recall of the LER; therefore, the LER neither altered his interpretation of the technical specification nor did it change the way he performed the test or handled the test results. Note: Mr. Illjes statements are in conflict with the LER submitted to thTWC on November 1,1978. The LER stated that the event was caused by misinterpretation of the requirements of the technical specifications and that appropriate personnel would be instructed on the requirements of applicable sections of the technical specifications and the requirement to immediately invoke applicable ,

action statements when the provisions of the limiting conditions for operation are not met. .

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7. Mr. Illjes believed that as the date of the accident approached, it was harder to get good leak rate test results because of high identified leakage through either the PORY or code safety valves. He stated that although he was concerned with operating the plant with high identified leakage, he did not recosmend that the plant be shutdown. At the time, he did not believe that was his judgement to make. He discussed the j leakage with his Shift Foreman and his shift Supervisor and was told that "they were going to do something about it." Note: Identified leakage did not exceed the technical specification M t of 10 gpm for

identified leakage prior to the accident.

8. Mr. Illjes stated that prior to the accident, he was unaware that hydrogen additions to the MUT could affect MUT 1evel indication and l' thus, favorably influence leak rate test results. Note: Mr. Illjes' '

Shift Supervisor (Mr. Joseph Chwastyk) was deposed on April 24,1984, as part of the TMI-1 leak rate investigation prepared for GPUN by Mr. Edwin Stier. During his deposition, Mr. Chwastyk stated that he first became

, aware of the effect of hydrogen on leak rate test results at THI-2 in late 1978 and that he believed this phenomenon was brought to his attention by one of his CR0s, specifically, Mr. Illjes.

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, 9. Mr.111jes testified that he never added hydrogen for the purpose of influencing leak rate test results and that he was not aware of this effect until sometime in 1980, after Hartman's allegations were made public. Note: Mr. Chwastyk stated that he conducted a test and personally observed the hydrogen effect on leak rate test results and implied the test was done when it was first brought to his attention.

Mr. Chwastyk also stated the he gave his operators directions not to add hydrogen when they were doing leak rate tests until Chwastyk could determine what was causing the problem.

10. Mr.111jes testified that he never intentionally added water for the purpose of altering leak rate test results. If water was added during a test and not included in the calculation. it was most likely caused by miscomunication between the operator performing the test and the operator on the panel who added the water. If water was added and the amount of water included in the leak rate calculation was less than

_ . amount indicated on the MUT strip chart it was caused by instrumentation errors between the totalizer and the strip chart. He was not aware that the two instruments might read differently. He stated that he was not aware that pressure changes in the MUT caused by the addition of water to the tank could be used to his advantage during the performance of a leak rate test.

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11. Mr.111jes .itated that since there were two fevel transmitters for MUT levelindication(i.e..onefeedingthestripchartandoneproviding input to the computer for leak rate calculations). it was possible to  :

affect leak rate test results by switching between level transmitters during the test. However, he stated he did not become aware of this phenomenon until after the accident.

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12. The technical analysis shows that between 09/30/78 and 03/28/79. 13 of the 18 tests (72%) involving Mr.111jes included actions that were contrary to the precautions and limitations of Surveillance Precedure 2301 3D1. These actions included: unstable plant conditions; use of an unstable MUT level transmitter to provide input to the computer; water additions that were not properly included in the calculation, and hydrogen additions to the MUT. During the period where identified leakage was high (01/01/79 to 03/28/79). 7 out of 8 tests (88%)

involving Mr. 111jes included these procedural errors. These are the same type of " procedural errors" that other operators have admitted to using to manipulate or influence the outcome of leak rate tests.

In sumary. While Mr.111jes' now considers that some of his actions regarding the conduct of leak rate tests were contrary to TMI-2 written procedures and technical specifications; he dentes that he performed 1 evolutions with the intent of influencing the outcome of leak rate test l results. Based upon the weight of the available evidence, including the high j number of invalid or questionable tests involving Mr.111jes. and the i testimony of Mr. Chwastyk it appears that either Mr.111jes was not truthful i regarding his knowledge of or involvement in leak rate test manipulation or

! he was grossly negligent in that he ran many tests and would knowingly accept only test results less than the technical specification limit, regardless of the evolutions in progress during the test.

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NOTE: This enclosure discusses information that is maintained in the NRC's Privacy Act System of Records (NRC-16). This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO. Internal access and distribution should be on a "need to know" basis.

Enclosure 2

Background

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On January 31, 1985, an interview was conducted with Mr. Theodore Illjes, a Senior Reactor Operator at Three Mile Island Nuclear Station Unit 2, in order to determine Mr.111jes' understanding of his responsibilities for the safe operation of the plant and his commitment to those procedures and operating principles necessary to carry out those responsibil.ities.

Participating in the interview from the NRC were William T. Russell, Deputy Director, Division of Human Factors Safety and Leonard Wiens Senior

. Examiner, Operator Licensing Branch. Mr. Smith 8. Gephart and Mr. James Moeller, attorneys representing Mr. Illjes, were also present at the interview.

In addition to the interview with Mr. Illjes, an interview was conducted with Mr.111jes' supervisor on January 30, 1985. The supervisor interviewed was:

Name Position / Title Mr. Sandy Levin Site Operations Director Section II provides a summary of the interviews with Mr. Illjes and Mr.

Levin. A summary of comments provided by the NRC Resident Inspectors are also included.Section III provides an overall conclusion regarding Mr. ~

Illjes' current performance.

II. Interview Summary Mr.111jes appeared to be a very conscientious, dedicated operator. He seemed to be sincerely committed to operating the plant safely and in accordance with all procedures and regulations. During the interview he demonstrated a very cautious, emasured approach to plant operations. He demonstrated a thorough knowledge of procedures and technical specifications and the ability to use them. When placed in postulated situations not covered by procedures, he displayed good judgement in his choice of actions and was quick to consult with management and the NRC to resolve problems.

His highest priority appeared to be ensuring that all evolutions conducted on his shift were done properly and in accordance with approved procedures.

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2 III. Conclusion No information was obtained from the interviews with Mr.111jes

. . . . . which could be used as a basis for revocation or modification of Mr.111jes' Senior Operator's License. _ . _ .

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The Senior Operator Upgrad'e Eiamina' tion Report used t'o record t ' he results of Mr.111jes' .

interview is included as Attachment 1 to this enclosure and the list of questions that were used during Mr.111jes interview is included as Attachment 2.

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'.[. "%

unirno stavas Enclosure 10

/ NUCLEAR REGULATORY COMMISSION g

.f w asee m o m . o.c.s m os U.S. IPC

\,....+/ October 4, 1985

.: r. I -9 FF.12: Deu f

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_'i'9.5.I.I

v. .

MEMORANDUM FOR: Harold R. Denton, Director Office of Nuclear Reactor Regulation FROM: William T. Russell, Acting Director Division of Human Factors Safety, NRR

SUBJECT:

RESULTS '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) and W. J. Dircks (EDO) dated April 2, 1984,

Subject:

Staff Requirements-Discussion of Pending Investigation-M1

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

Subject:

NRR Review of O! Investi-gation Materials Concerning Hartman Allegations of Falsification of Leak Rate Data at 1HI, Unit 2

3. Memorandum from W. T. Russell (DHFS) to H. R. Denton (NRR) dated January 24, 1985

Subject:

Follow-up Action on Additional TMI-2 Operators i Th purpose of this memorandum is to document the results of the joint 01/NRR in stigation and evaluation of Mr. Hugh A. McGovern, a licensed Senior Ret tor Operator (SRO) at Three Mile liland, Unit 2 (TMI-2), currently ,

ser. Ing as the Plant Operations Manap r, and to provide a recommendation rehrding whether his current SRO license should be revoked, modified, or st',Mnded under 10 CFR 55.40 or other enforcement action taken under 10 CFR PJrt 55.50, due to his involvement in preaccident leak rate testing frW gularities at TMI-2.

Background

1 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

\

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NOTE: This memorandum and Enclosure 1 discuss information which is the subject of an ongoing O! investigation. This memorandum and Enclosure l 2 discuss information that is maintained in the NRC's Privacy Act i System of Records (NRC-16). This memorandum and enclosures may not be l disseminated outside the NRC without coordination with NRR and the i permission of the EDO or the Director. OI. Internal access and distribution should be on a "need to know" basis, 40 ye ,L [ f/d b I 1~Lf,

Harold R. Denton October 4,1985 those matters which required further investigation. The results of NRR's review was provided in Reference 2. The review detemined that follow-up investigation was warranted in the case of seven operators who were currently licensed. Mr. McGovern was not one of those seven individuals.

At a follow-up Comission meeting on May 23, 1984, the Comission agreed with the approach of evaluating past and present perfomance. 01 and NRR would conduct a joint investigation to determine what role, if any, these individuals had in improper activities associated with leak rate surveillance testing at TMI-2 prior to the accident, and NRR would conduct an evaluation of the current performance of these individuals. Based upon the results of the investigation and evaluation NRR would~recomend to the Comission what action, if any, should be taken against each of the identified operators.

As a result.of some of the early interviews with these individuals and i further tec6nical evaluation, Reference 3 recomended that three additional l licensed ope'rators 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 currently licensed on TMI-2 and one is licensed on San Onofre 2 and 3. The remaining two individuals were licensed c,a Waterford 3, but have subsequently 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 hint 01/NRR interview of Mr. Hugh A. McGovern, Jr. was held in the Three Mile Island Training Facility, Middletown, Pennsylvania.

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

attorney. The purpose of the interview was to determine Mr. McGovern's role, if any, in improper activities associated with RCS leak rate surveillance testing at TMI-2 prior to the acetdent on March 28, 1979. At that time, Mr. McGovern was a Control Room Operator (CRO) assigned to Shift "A" and later Shift "F." A detailed evaluation of Mr. McGovern's involvement in leak rate testing irregularities is provided in Enclosure 1 to this memorandum.

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 i

Shift Foreman and other CR0s on his shift. Mr. McGovern admitted that many i of his actions, associated with leak rate testing, violated approved plant procedures and technical specifications; however, he denied any personal involvement in or knowledge of leak rate test manipulation.

Based upon the results of MRR'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 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.

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Harold R. Denton October 4,.1985

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

3. Contrary to Surveillance Procedure 2301-301, "RC System Inventory," when test results indicated unidentified leakage in excess of the limiting condition for operation (i.e.,1 gpm), Mr. McGovern did not enter the action statement of Technical Specification 3.4.6.2, " Reactor. Coolant System Operational Leakage."  !

1

4. Contrary to TMI Administrative Procedure 1012. " Shift Relief and Log l s

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 i

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.

i 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 1

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 t

make-up tank (MUT) level transsittters. IpeNRRevaluationshowsfourof 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 i

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. .

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i

Harold R. Denton October 4, 1985

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

12. Mr. McGovern testified that he was generally aware of instromentation

' 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 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 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 sunnary, Mr. McGovern agrees in retrospect that many of the actions involving leak rate surveillance testing at THI-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 test " meaningless" as far as representing true plant leakage.

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

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 tests were conducted so frequently, Mr. McGovern was negligent by failing to

• i i

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 gpe, he would retain it with little or no review to ensure it was a valid

• test.

, Current Perfomance~ -

On June 3, 1985, NRR conducted an interview and oral examination of Mr. McGovern in order to detemine his understanding of his responsibilities

, for the safe operation of the plant and his commitment to those procedures and operating principles necessary to carry out those responsibilities. In order to obtain additional background infomation on Mr. McGovern's current performance, joint TMIP0/NRR interviews were conducted on May 17, 1985, with TM1-2 management personnel and the NRC's Resident Inspectors for TMI-2.

Enclosure 2 to this memorandum contains the evaluation of Mr. McGovern's current perfomance as well as: (1) a summary of the background interviews; (2) the Senior Operator Upgrade Examination Report used to record the results of Mr. McGovern's interview; and (3) a copy of the questions asked of Mr.

McGovern and a summary of his responses.

In general, Mr. McGovern appeared to be a very confident, knowledgeable, and cooperative operator. He seemed to be comfortable proposing solutions or actions for the various hypothetical situitions which were presented to him by the interviewers. In all instances he followed a safe, conservative, yet i

i

rold R. g October piM85 practical course of action. At all times, he appeared comitted to operating the plant in accordance with approved operating procedures and sound operating principles. He demonstrated a thorough knowledge of plant procedures and technical specifications, and was particularly knowledgeable of administrative requirements and procedures. The overall tapression was that Mr. McGovern was a very experienced, highly competent, aggressive senior i operator, comitted to oeriormino his duties in accordance with good operating practices. ,, .

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. s In sumary no information was obtained from the interviews with .

Mr. McGovern. _ ,

which could be used as a basis for '

revocation or modificat' ion of his Senior Operator License. ,

Conclusions and Recomendation During the period under investigation, while Mr. McGovern served as CRO-in-trainir.g 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 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 CR0's Log; ,

j

4. Fat ure to take the required follow-6p action when the limiting l

conditions for operation specified in the TMI-2 Technical Specifications werd exceeded; ~

5. personally throwing away leak rate test results which exceeded the limits of the TMI-2 Technical Specifications.

Despite these actions. Mr. McGovern dentes 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 was grossly negligent in his duties as a Control Room Operator with respect to leak rate surveillance testing. -

Based upon the testimony of the majority of other CR0s and Shift Foremen interviewed to date. it is clear that management's standards for procedural compliance were tax and pemissive. In my opinion, this was created through negligence on the part of management. ...Lack .......ofoperator respect for the

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In this case, Mr. McGovern may not have been involved in leak rate test manipulation; however, based on his stated opinion that the test was a meaningless. administrative requirement that bore little resemblance to actual 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.

I beileve'Mr. McGovern ha's'learnedirce his pasEmistakes, does understand his duties and responsibilities for condicting safe operations at TMI-2. and that he is constitted to following approved procedures and principles necessary to carry out those responsibilities. I also believe that he imparts this same sense of responsibility to his subordinates.

1 -

. , . I recosinend that no enforcement action be -

taken against Mr. McGovern.

UrYgYnar signea Br nunu 1. mss LL liilliam T. Russell, Acting Director

! Division of Human Factors safety Office of Nuclear Reactor Regulation

Enclosures:

As stated ,

cc: S. Mayes .

K. Christopher l

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NOTE: This enclosure discusses information which is the subject of an ongoing OI investigation. This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO or the Director. 0I. Internal access and distribution should be on a "need to know" basis.

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

!. Background OnJune4,1985,ajoint'OfficeofInvestigations(OI)/0fficeofNucle'ar ~

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 activities associated with reactor coolant system (RCS) leak r. ate surveillancetestingatThreeMileIsland, Unit 2(TMI-2)priortothe 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 Musan 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 B. Gephart of the law fira Killian & Gephart, Marrisburg, Pennsylvania. A copy of the transcript of Mr. McGovern's interview is included as Attachment 1 to this enclosure.

i Mr. McGovern is employed by General Public Utilities Nuclear Corporation (GPUN). He currently holds the position of Plant Operations Manager TMI-2 andisalicensedSeniorReactorOperator(SRO)onTMI-2. Mr. McGovern began his employment with Metropolitan Edison Company (Met-Ed) on October 11. 1976,'

as an Auxiliary Operator (A0). He served in that capacit one year before entering the Control Room Operator (CRO) y for training approximately program.

receivinghisReactorOperator's(RO)licenseinNovember1978. He remained a Itcensed 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 sumarized information was extracted. Overall findings and conclusions regarding Mr. McGovern's involvement in improper. activities asscetated with TMI leak rate survaillance testing are presented in Section IV of this enclosure.

a II. Sumary of the Technical Analysis In 1983 and early 1984, a technical analysis of the leak rate surveillance I tests conducted during the last six months of operation of THI-2 was l performed by the NRC. This analysis was done as technical support to the Department of Justice (D0J) in its criminal proceeding against het-Ed. In i 1985, NRR perfomed a reevaluation of that analysis by factoring in j 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 2 to this enclosure, a discussion 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 " demonstrate that reactor coolant system (RCS) leakage did not exceed the limiting conditions for operation. THI-2 Technical Specification l 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-hours 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 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 pressurizer 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 would be signed by the operator perfoming the test and approved by an SRO.

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

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

, licensee during the period under investigation, Mr. McGovern was involved in l 14 leak rate surveillance tests. The table below shows a breakdown of NRR's overall conclusions regarding these tests. -

Breakdown of Leak Rate Tests Perfomed by H. A. McGovern Evaluation Category Number of Tests Total numbe r of te s ts on fi 1 e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Tests with no apparent problems.................................... 4 Unstable or out-of-service makeup tank (MUT) level transmitter..... 4 Water additions to MUT (partially included in the calculation)..... 3 Water additions to MUT (not included in the calculation)........... 1 Feedandbleedoperations(notincludedinthecalculation)........ 2 Water or hydrogen addition (unable to differentiate)............... 1 Note: One test (#50) falls into two evaluation categories.

. , . 1 l

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 governing the conduct of leak rate tests (SP 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 esch test is presented below.

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

surveillance procedure are tests #99 (02/03/79), #103 (02/05/79), #109 (02/08/79),and#116(02/13/79).

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 level strip chart recorder in the control room while the other level 4

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

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

• I (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 Thesetestswere:#50(12/08/78),#64 3

- p(roviding)inputtothecomputer.12/16/78 , f73 (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.

The offset could have been caused either by the switching of LTs during the test or an unaccounted for addition of approximately 60 gallons of water during the test. There are no log entries in the CRO's Log or Shift 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  :

l have been involved in Test #80 (12/30/78). This test was started on  !

McGovern's shift and completed and signed by the next shift. The use of LT-1 l l in this case again produced a significant error in test results. Instead of

! MUT level decreasing approximately 2.0" during the test, the computer read ,

i the change in MUT level as +3.95". This difference caused the unidentified leak rate to be calculated as -3.8 g;m.

4-Thus, during the entire period of time LT-1 was essentially "out-of-comission," 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. These actions resulted in a meaningless calculation of unidentified leakage that could not demonstrate conformance with the technical specification limit of 1 gpm. .

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 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 fill appears to have have been started during the bleed portion of a feed and bleed operation which was begun about 20 minutes prior to the start of the test. The amount of water bled from the RCS was not included in the 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

net positive suction head for the ACS makeup pumps, a hydrogen overpressure was maintained in the MUT. When hydrogen pressure decreased near the low end

. of the operating band, the CR0 would add hydrogen to the tank.

Theoretically, the addition of hydrogen should not have affected MUT level; however, because of the configuration and environment of the MUT level detection instrumentation system at TMI-2, water could collect in the

low-pressure (dry) reference leg of the level transmitters. Under these l 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 l 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 additionduring)the' 2" rise (60 gal in MUT test. Approximately level indication thathalfway can notthrough the testfor be accounted there by is a 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 on leak rate test results.

Because adding water to the MUT compresses the hydrogen 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 addition. If an operator were aware of this cause and effect relationship leading to this l " instrumentation inaccuracy," (without having to know it was caused by the i " loop seal" effect described above), he could take advantage of this phenomenon to manipulate test results by following the procedure exactly as written. For example, the addition of 150 gallons of water to the MUT during the last 15 minutes of a leak rate test should cause the MUT 1evel to increase 5 inches (30 gal / inch); however, if sufficient water had collected in the loop seal, the indicated level cn the MUT strip chart might actually l

l

. increase 6 inches (180 gal). Once the final data was read by the computer, including the 6 inch rise in MUT level, the operator would enter the 150 .

gallon water addition into the computer as an operator-caused change. Thus, when the computer calculated the net unidentified leak rate, the leak rate result would be 0.5 gpm less than the actual leak rate [(180 gal - 150 gal)/

50 minutes].

i Former TMI-2 CR0 Mark Coleman stated during his joint 01/NRR interview on December 14, 1984, that he was aware of this phenomenon and intentionally added water near the end several leak rate tests in order to take advantage of this phenomenon to help his get tests results with the limits of the technical specifications. The technical anal perfomed by Mr. Coleman's shift (Shift "D") ysis Mr.

supports of leak rate tests Coleman's adnission. 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.

Computer MuI 5 trip Error Time before Test # Date Input Chart Produced End of Test CRO-Test .CRO-Panel 150 03/17 207 gal 240 gal 33 gal 24 mins McGovern Hemila 151 03/19 200 gal 330 gal 130 gal lain McGovern Hamila 153 03/22 200 gal 300 gal 100 gal 7 min McGovern Hemila Key: Computer Input = amount of water included in test calculation by CRO.

MUT 5 trip ciart = amount of addition indicated on MUT strip chart.

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

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

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

CRO-Panel = CR0 who was on the panel during test and who signed the GRD'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 PORV and/or safety valves increased. As a result, operators were forced to add a '

. 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 detemine whether the operators were unknowing victims of this instrumentation error or were aware of the situation and used it to there advantage.

In sumary, the technical analysis shows that between SepteNer 30,1978 and March 28,1979,10 of the 14 tests (717.) involving Mr. McGovern included actions that were contrary to the precautions, limitations, and requirements of Surveillance Procedure 2301-3DI. These actions included accepting tests:

w-,ay-wy---wv--- - - - - -- -- - - - --- -

i that were run on the unstable or inaccurate MUT level transmitter; contained j 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 i 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, regardless of the evolutions in progress during the tests. Nevertheless, there is no-clear pattern that these evolutions were performed with the intent of wrongfully influencing leak rate test results. In addition, while some of these actions 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 01/79-03/79 Shift Supervisor: Bill Zewe Ken Bryan Shift Foreman: Fred Scheimann Carl Guthrie CRO: Ed Frederick Earl Hamila CRO: Craig Faust Hugh McGovern CRO-in-training Hugh McGovern* Lynn Germer

• In training until receiving his R0 license in 11/78.

Sge page 5.

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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 THI-1 and TMI-2 and ran the shift for Doth units. McGovern, stated that he had little interface with plant mana He would see the SupervisorofOperations(JimFloyd)gementatthetime.andthePlantManager(JoeLogan)in control room on occasion and he would answer any questions they may have had; however, routine instructions would normally go through the Shift Supervisor and the Shift Foreman. See_ 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. Me said the problems were known outside~the Operations Department. In particular, the Instrumentation & Control (I&C) tecinicians worked on some of the level and temperature indications that fed into the computer program and the computer programing group worked ch the computer program from time-to-time. Mr. McGovern felt that the majority of problems with the leak rate test were associated with inaccurate input from instru:rentation and frem improper temperature compensation in the program.

S_ee pages 8-10.

Mr. McGovern said they did not pay a great deal of attention to the perfomance 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 the computer te start the test and one hour later would enter the necessary infomation to account for any operator-caused changes and the computer would calculate and printout the leak rate information. The operator performing the test would try to. keep the panel operator informed that a test'was in progress. This would be done in an informal manner. According to McGovern, sometimes plant conditions would be such that water additions had to be made during the test, even though they tried to avoid it. In each case, however, they would include the w4ter addition in the leak rate calculation. See pages 10-12.

Even though the TMI-2 Technical Specifications required a leak rate test be 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 administrative requirement that they had to meet every three days.

_ Therefore, any test results that exceeded the technical specification limit' of 1 gpm for unidentified leakage would be discarded. Each shift would continue to run tests until a satisfactory result was obtained. McGovern stated it was connon practice to run tests in this manner as long as he had been in the control room. Because the test was considered an administrative requirement. Mr. McGovern did not give any thought to throwing away bad tests. He did not really relate it to the technical specification requirements. jee pages 12 and 13.

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

. operators had two choices for detemining 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 equais 30 gal. He said neither instrument was perfectly

accurate. They both has some error. jeepage15.

~

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 would either discard the test himself or put in in the Shift Foreman's desk and infom him that "it didn't come out." jeepages17and18.

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

I Note: During a routine inspection of TMI-2 operations on October 18 1978, and NRC inspector discovered several bad leak rate tests lying in the control roem and that TMI-2 had been operating for an extended period l

l l

8-I of time with unidentified leakage exceeding the technical 4

specification limit. The incident resulted in the submittal of 1 LicenseeEventReport(LER)78-62/1T.

The LER stated in part: "This event was caused by a misinterpretation of the requirements of the technical specifications....The appropriate personnel will be instructed on the requirements of appitcable sections of the T.S. and the requirements to imediately invoke applicable i actions statements when the provisions of the LCOs [ limiting  !

conditions for operation] are not met." )

< . i 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 sp'ecifications, 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.

t 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, and 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-them. McGovern was informed 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 acticn statement. McGovern was asked how his Shift Foreman could be aware of this situation 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 them. See pages 25-27.

l It was pointed out to Mr. McGovern, that if the results of a surveillance l test was unsatisfactory TMI Administrative Procedure 1010. " Technical Specification Surveillance Program." required that correctiva 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 technical specifications in the Control Room Log. Mr. McGovern responded by reiterating that leak rate tests were treated as a " computer program administrative function" and not as a surveillance function, thus, start and stop times of all tests were not logged. He did not recall, hcwever, anyone ever indicating to him that he should not log the start times s

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

Mr. McGovern 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 perforined during the test that would render the test invalid, would he still keep it? Mr. McGovern responded by stating that they would try to ensure the plant was stable during the test and they accounted for all additions. However,Mr.'McGovern 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 gpm 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. j,eepages28-31.

e

~

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 -

l 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 sianually enter the value for identified leakage from sources other than the Reactor Coolant Drain Tank (RCDT),aswellas.steamgeneratortubeleakageandoperator-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 surgrised, however, that most of the tests showed this term to be

! zero, because we weren't very good about administering that particular test." Se.,pages 31-33. - -

Mr. McGovern was asked if he could recall problems with the MUT 1evel

. transmitters (LTs).,Hesaidtherewereproblemswithbothofthemfromtime to time. When there were problems, he believes as a CRO, 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.

53 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. See page 36.

The next portion of the interview with Mr. McGovern centered around Hartman's l allegations that leak rate tes.ts results were manipulated by operators l through the use of water and hydrogen additions to the MUT. McGovern stated l the he had no personal knowledge of any operator, including himself, intentionally performing actions that would influence the outccme of leak rate tests. He said, at the time, he was not aware that hydrogen could

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

i i

affect MUT level and consequently leak rate test results. McGovern also fimly 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 was aware of a significance difference ~between

~

the amount of water added, as shown on the batch. controller and the amount of water added, as shown b the rise on the MUT strip chart. Mr. McGovern stated that he probabl had noted a difference; however, he could not recall anything specific. Mc 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 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 *arbitraryandcapricious."je,e,pages38-42.

e The next portion of the interview involved a detailed discussion of the leak rate tests involving Mr. McGovern. After reviewing tests for which unstable LT-1 was used as input to the computer (Tests #50, 64, 73 and 74) and tests involving possible feed and bleed operations (Tests #106 and #111) McGovern was told that it appeared that they did not pay particular attention to -

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 determine the affect of hydrogen on leak rate test results. Mr. McGovern stated that he was not aware such a test had ,

i 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 j without logging it. See e pages 58-62.

Next, the three tests involving "underrecorded" water additions (Tests #150, 151, and 153) were reviewed with Mr. McGovern. McGovern could not recall why 1 water was added to the MUT during these tests and why the amount included in 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 *

outcome of a leak rate test. See,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 j problems with the test that may have led some operators to perfom certain j actions to influence the outcome 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 worked with intentionally manipulated leak rate test

..-----.y-- .--

i 1

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, at one point almost daily, and the computer personnel were working on correcting the computer program. Hepages6g-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 RCDT to the bleed tanks, and having to recirculate the gressurizer to equalize boron concentration, he did not consider it particularly unhealthy." h e pages 72 and 73. .

In closing the interview, Mr. McGovern was asked if it was his position, that while some 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, 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 pages 75 and 76.

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 performance 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 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 l

rate tests indicating unidentified leakage in excess of 1 gmi were i discarded, either directly by Mr. McGovern or by his Shift foreman.

3. Contrary to Surveillance Procedure 2301-3D1, "RC System Inventory," when test results indicated unidentified leakage in excess of the limiting l condition for operation (i.e.,1 spm), Mr. McGovern did not enter the action statement of Technical Specification 3.4.6.2, " Reactor Coolant System Operational Leakage."

L________________.________ _ _ _ _ _ __. _ _ - . . _ - . _ _ _ _ . _ , _ _ _ _ _ _ . - _ _ _ _ . _ - - . , _ .

,,. - as a-, A - ,"-

4. Contrary to TMI Administrative Procedure 1012. " Shift Relief and Log 4 Entries," Mr. McGovern did not log the start time, stop time, and the i results of all leak rate surveillance tests in the Control Room Log.

5. to TMI Administrative Procedure 1010. " Technical Specification ContrarfanceProgram,"an"ExceptionandDeficiencyList"wasnot Surve11 completed by Mr. McGovern and submitted to the Shift Supervisor for j 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/IT, 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 />. Me 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 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.

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 l

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 l during the test.

l

11. Mr. McGovern testified that he had no personal knowledge of any operator l

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

l 12. Mr. McGov'ern testified that he was generally aware of i strumentation inaccuracies between the batch controller and the MUT level indicators; hcwever, he did not take advantage of those inaccuracies during the performance of leak rate tests. The NRR evaluation shows three of f

w--.,-c--._e.,r- ,ge,,-

Mr. McGovern's tests involved water additions, where the amount of water logged in the CRO's Log and included in the leak rate calculation were less than the amount 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 sunnary, Mr. McGovern agrees in retrospect that many of the actions involving leak rate survei lance testing at TMI-2 violated approved procedures and were contrpry to the THI-2 Technical specifications. plant Because of problems with instrumentation and the procedure itself Mr. McGovern considered the test " meaningless" as far as representing.true plant leaka As a result, the test was treated as an administrative requirement only. ge.-

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 tests were conducted so frequently, Mr. McGovern was negitgent 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.

9 O

i A

1 so I

j i

NOTE: This enclosure discusses infomation that is maintained in the NRC's Privacy Act System of Records (NRC-16). This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO. Internal access and distribution should be on a "need to know" basis.

Enclosure 2 .

I. Background on June 3,1985, an interview was conducted with Mr. Hugh A. McGovern. Jr., a l Senior Reactor Operator at Three Mile Island Nuclear Station. Unit 2 in order to detemine Mr. McGovern's understanding of his responsibilities for the safe operation of the plant and his consnitment to those procedures and operating pr.inciples necessary to carry out those responsibilities.

Participatin'g in the interview from the NRC were Mr. William T. Russell.

Acting Director. Division of Human Factors Safety and Mr. Leonard Wiens, Senior Examiner. Operator Licensing Branch. Messrs. Smith 8. Gephart.and James Moeller and Ms. Jane Penny, attorneys representing Mr. McGovern were also present during the interview.

Additional background infonnation was obtained on Mr. McGovern's current performance through interviews. conducted on May 17, 1985 with TMI-2 management personnel and the NRC's Resident Inspectors for TMI-2. These interviews were conducted by Mr William D. Travers. Deputy Program Director, i TMI Program Office and Mr. Wiens. The per:onnel interviewed included:

Name Position / Title Mr. Sandy Levin Site Operations Director. TMI-2 Mr. William Kelly Manager Management Services. TMI-2 i Mr. Ronald Cook Senior Resident Inspector. THI-2 -

Mr. Thomas Moslak Resident Inspector. TMI-2 Section 11 contains a sumary of the interview with Mr. McGovern, and'the individuals listed above.Section III provides an overall conclusion*

regarding Mr. McGovern's current perfomance.

II. Interview Sumary Mr. McGovern appeared to be a very confident knowledgeable, and cooperative

operator. He seemed to be comfortable proposing solutions or actions for the various hypothetical situations which were presented to him by the l

interviewers. In all instances he followed a safe, conservative, yet

'l practical course of action. At all times, he appeared cocinitted to operating the plant in accordance with approved operating procedures and sound operating principles. He demonstrated a thorough knowledge of plant procedures and technical specifications, and was particularly knowledgeable of. administrative requirements and procedures. The overall impression was that Mr. McGovern was a very experienced, highly competent aggressive senior operator comitted to perfoming his duties in accordance with good operating practices.

9 4

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1. .

III. Conclusions No information was obtained from the interviews with Mr. McGovern,

.. . . . ., . . .. . concerning Mr. McGovern's current pe'r fonnance which could be used as a basis for revocation or modific.ation of Mr. McGovern's Senior Operator License. Based on the results of the interviews, he appears to be a significant asset in the smooth, safe performance of the daily evolutions at the plant.

The Senior Operator Upgrade Examination used to record the results of Mr. McGovern's interview is included as Attachment 2 and a copy of the questions asked to Mr. McGovern, along with his responses are included as Attachments 3 OI e

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a

)# De y ,,7g ,,7,7g, Endoswe H 8 o NUCLEA84 REGULATORY COMMISSION ,

s  ! =4s mom =.o.c.mmu September 6, 1985

(..... .

j MEMORANDUM FOR: Harold R. Denton. Director -

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

SUBJECT:

RESULTS OF JOINT 01/NRR INVESTIGATION AND EVALUATION OF

. ADAM W. MILLER

Reference:

1. MemorandumfromS.J.Chilk(SECV)toB.B; Hayes (01)

, and W. J. Dircks (ED0) dated April 2,1984,

Subject:

• Staff Requirements-Discussion of Pending Investigation-

$ MI

2. MemorandumfromH.R.Denton(NRR)toB.B. Hayes (01) dated May 3, 1984.

Subject:

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

3. MemorandumfromW.T. Russell (OHFS)to'H.R.Denton (NRR)datedJanuary 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. Adam W. Miller, a licensed Senior Reactor

! Operator (SRO) at Three Mile Island, Unit 2 currently serving as the Manager

• Plant Operations, and to provide a recomendation regarding whether his current SRO license should be revoked, modified or suspended under 10 CFR

! - 55.40 or other enforcement action taken under 10 CFR Part 55.50, due to his

! involvement in preaccident leak rate testing irregularities at TMI-2.

Background

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

! NOTE: This memorandum and Enclosure 1 discuss information which is the '

subject of an ongoing OI investigation. This memorandum and Enclosure

! 2 discuss inform 6 tion that is maintained in the NRC's Privacy Act SystemofRecords(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, p , e e pLo G PI l

~- _

j September 6,1985 those matters which required further investigation. The results of NRR's j review was provided in Reference 2. The review determined that follow-up investigation by 01 and further evaluation by NRR was needed in the case of seven currently licensed operators. Mr. Miller was not one of those seven individuals. At a follow-up Comission meeting on May 23, 1984 NRR proposed l joint 01/NRR investigations and evaluations of these individuals.-

i Subsequently, NRR issues letters to these individuals under 10 CFR 55.10(b) i requesting additional information regarding current performance. Based upon

, the joint investigation into the individuals' past involvement in improper activities at TMI-2 and an evaluatiori of the individuals' subsequent i' performance, NRR would recomend what action, if any, should be taken against the identified operators. As a result of some of the early interviews with these individuals and further technical analysis Reference 3 recomended j that three additional currently licensed operators also be interviewed. Mr.

I Miller was one of the operators identified in Reference 3. NRR issued similarlettersto,theseindividualsunder10CFR55.10(b). Of the i ten individuals identified for investigation, seven are currently licensed on TNI-2, two are licensed on Waterford 3 and one is license.d on San Onofre 2-1 and 3.

1 j Past Involvement in TMI-2 Leak Rate Testing Irregularities On June 5,1985, a joint 01/NRR interview of Mr. Adam W. Miller was held at the Three Mile Island Training Facility, Middletown, Pennsy.lvania. The -

interview was conducted in the presence of Mr. Miller's personal attorneys.

The purpose of the interview was to detemine Mr. Miller's role, if any, in improper activities associated with RCS leak rate surveillance testing at THI-2 prior to the accident on March 28, 1979. At that time Mr. Miller was a licensed Senior Reactor Operator (SRO) and served as the Shift Foreman for i Shift "D." A detailed evaluation of Mr. Miller's interview and a sumary of the technical analysis of leak rate surveillance tests involving Mr. Miller are provided in Enclosure I to this memorandum.

I During the interview, most of Mr. Miller's responses to general questions j associated with RCS leak rate surveillance test problems at TMI-2 were

consistent with statements made to the NRC by other licensed operators, including two of the three Control Room Operators (CR0s) on Mr. Miller's shift (Messrs. Mark Coleman and Lynn Wright). However, Mr. Miller denied any personal involvement in or knowledge of leak rate test manipulation by the operators conducting these tests on his shift. Based upon the results of NRR's technical evalustion an(the testimony of Mr. Miller and the three CR0s on his shift, the following findings and conclusions are drawn.

1. TMI-2 Technical Specification 4.4.6.2 required that RCS leakages be demonstrated to be within limits by the perfomance of a RCS water inventory balance (leak rate test) at least once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during i steady state operation. TMI-2 Technical Specification 3.4.6.2 limited unidentified leakage to 1 gpm. On Mr. Miller's shift, leak rate tests were routinely run at least once per shift, plant conditions and

evolutions permitting.

2. TMI Administrative Procedure 1012. " Shift Relief and Log Entries,"

required the title, number, start and completion times of all periodic tests required by the technical specifications (i.e., leak rate tests) be logged in the CR0's Log. Contrary to this requirement only O

F._ - -

I September 6, 1985 satisfactory (i.e., unidentified leakage less than 1 gpm) leak rate tests were logged in the CRO's Log by Shift "D" personnel.

3. Because Shift "0" perfomed leak rate tests more frequently than required by the technical specifications, only satisfactory tests were considered surveillance tests. Tests with results in excess.of the technical specification limits were not considered surveillance tests and were discarded. This action was contrary to TM!-2 Technical 4 Specification 6.10.1.d " Record Retention," which reqaired that l

records of surveillance activities required by the technical

! specifications be retained for a period of at least 5 years. Mr.

i Miller was not sure how this practice originated; however, it had existed for years and was consnon practice all shifts.

4. Because leak rate tests were run so frequently, the CR0s on Shift "D" conducted these tests on their own as part of their shift routine. If i tests results exceeded the limits of the technical specifications, the

{' _ , CR0s frequently discarded tests on their own. If an unsatisfactory '

test was provided to Mr. Miller, he would personally discard the test and instruct the CR0s to perfom another test.

5. In reviewing leak rate tests, Mr. Miller gave them a very cursory look before signing his approval. He essentially just looked at the bottom j line numbers. As long as the results did not exceed the technical specifications, he would approve the test.

• i

6. In general, Mr. Miller believed that prior to the accident, the general attitude of " don't worry abcut the paperwork just keep the hardware operating" was imparted to the operators by the Supervisor of j Operations, Mr. James Floyd.

7. Surveillance Procedure 2301-301, " Reactor Coolant System Inventory,"

required the operators to enter the action statement of Technical Specification 3.4.6.2, if unidentified leakage exceeded 1 gpm. The

! action statement required leakage to be reduced within limits within 4 i

hours or be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in cold shutdown within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />. Mr. Miller believed that he and his CR0s were aware of these requirements at the. time.

Nevertheless, as long as a satisfactory leak rate test was obtained within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> of the last satisfactory test, the action statement was not invoked, regardless of how many unsatisfactory test results were ,

received in the interim. This policy of accepting good tests and ignoring bad tests was also practiced by all shifts.

4

8. Mr. Miller stated that unidentified leakage of 1 gpm was not only the triggering point for entering the action statement of the technical specifications, but it also required notification to the NRC and was

the triggering point for entering the Emergency Plan as an unsual event. He believed that people may have tended to look the other way 4

and ignore tests that had results greater than 1 gpm because they did l not want to trigger those actions.

) 9. Although Mr. Miller had initialed the routing sheet for LER 78-62/1T, he did not have a preaccident recall of the incident. Contrary to 1

A

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l

. September 6, 1985 statements in the LER that the event was caused by a misinterpretation of the requirements of the technical specifications and that operators would be instructed to invoke the action statement when the limiting condition for operation was exceeded Mr. Miller did not recall being advised or instructed in this matter. Consequently, he neither changed his interpretation of when the action statement should be invoked nor provided any revised guidance to the operators on his shift. He did not believe there were any changes made to leak rate testing practices at TMI-2 as a result of this incident.

I

10. Mr. Miller stated that he was not aware until after the accident that adding hydrogen to the MUT towards the end of a leak rate test could affect MUT level indication and consequently leak rate test results. He-disagreed with Mr. Coleman's testimony that this phenomenon was comon knowledge among Shift Foremen and Shift Supervisors. Mr. Miller stated he had no personal knowledge at the time that anyone on his shift manipulated le~ak rate test results by the addition of hydrogen.

~

11. Mr. Miller stated that he was not aware until after the accident that adding water to the MUT just prior to the end of a leak rate test "

could produce the same effect on MUT level and leak rate test results as adding hydrogen. Aft'er the accident, Mr. Miller had reviewed all of the leak rate tests perfomed by his shift. He could not see any legitimate operational reason why, day after day, his shift had to add

, water to the MUT five to ten minutes before the end of'the test. Mr.

! Miller agreed that if his operators were taking advantage of instrument errors by adding water and using the number off the batch controller as the amount of the addition, knowing that the computer J was going to read the water level off the MUT level instrument, they

, were manipulating test results.

! 12. After reviewing Shift "D" leak rate tests Mr. Miller stated that while it appears fairly obvious now that his operators may have been taking advantage of perturbations in the MUT level transmitters to influence the outcome of leak rate tests, he stated he had no knowledge of this activity at the time. He had no suspicions that this was occurring on his shift or any other shift. He had no conversations with other Shift Foremen who indicated suspicion on their i part that operators on their shifts were performing these actions.

13. Mr. Miller did not believe that if operators were manipulating test results it was caused by pressure from their supervisors. He could only speculate that it may have caused by some misguided pride, competition or one-upmanship between shifts.

In sumary, Mr. Miller 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 TM1-2 Technical Specifications. Mr.

Miller was aware that as Shift Foreman it was his responsibility to ensure his shift's compliance with the technical specifications. Mr. Miller also agrees that there is strong evidence, including the testimony of Mr. Coleman, to indicate operators on his shift were performing actions that were contrary to intent and/or spirit of the leak rate test surveillance procedure and that i

1 l

i

September 6,198.

these actions were done with the intent of influencing or manipulating the outcome of leak rate surveillance tests. Nevertheless, Mr. Miller states that prior to the accident, he had little involvement in the performance of leak rate tests and'had no involvement in or kncwledge of operators en his shif t ir.tentionally manipulating the outcome of test results.

The results of the technical analysis indicate that of the six shifts standing watch during the last three months of operation of THI-2. Shift "D" had the highest percentage (93%) of " questionable" leak rate tests. The vast majority of these questionable tests show water additions to the MUT during the last few minutes of the test resulting in a calculated leak rate that was smaller than the actual leak rate. Despite conflicting testimony by the three CR0s, as to why the water additions were made, the weight of the evidence would indicate that these additions were made to intentionally influence the outcome of leak rate surveillance tests. While Mr. Miller was not directly involved in the actual conduct of the tests and his statements that he did not order or direct the manipulation of tests are credible and are supported by the operators' testimony, it is not plausible that Mr. .

Miller was unaware that leak rate test manipulations were taking place on his shift.

Current Performance On June 3,1985, NRR conducted an interview and oral examination of Mr.

l Miller in order to determine his understanding of his responsibilities for the safe operation of the plant and his cosw.itment to those procedures and operating principles necessary to carry out those responsibilities. In order to obtain additional background informa*fon on Mr. Miller's current performance, joint TMIP0/NRR interviews were conducted on May 17, 1985 with TMI-2 management personnel and the NRC's Resident Inspectors for TMI-2.

' Enclosure 2 to this memorandum contains the evaluation of Mr. Miller's current perfonnance as well as: (1) a sumary of the background interviews; -

(2) the Senior Operator Upgrade Examination Report used to record the results of Mr. Miller's interview; and (3) a copy of the questions asked to Mr.

l ,

Miller and a sumary of his responses.

In general, Mr. Miller appeared to be a cautious, conservative operator, intent on ensuring that the stated actions would be in conformance with approved procedures and operating principles. Although somewhat hesitant in response to some of the hypothetical situations, overall he seemed very knowledgeable of the requirements of the operating procedures. THI-2 Technical Specifications and the facility administrative requirements. He also appeared to be comitted to operating the plant in accordance with approved operating procedures and sound operating principles and requiring the same compliance from his subordinates. Overall, Mr. Miller seemed to be a highly competent, cautious and dedicated Senior Operator who would take those actions necessary to ensure that plant evolutions were conducted safely and in full compliance with plant and NRC requirements.

In sumary, no information was obtained from the interviews with Mr. Miller, enne.rninn ur M4 m e u enrron+

n y ~~ - +perforbance which could ner s-sentor operator be used ttee as a basis for revocation or modification of sser wream tounopraen trshtft---- - - - - - - - - -

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6-September 6,19L operations combined with his comitment to strict procedural compliance is a significant asset in the safe operation of the plant.

Conclusions During the period under investigation, while Mr. Hiller served as the S'nif t Foreman at TM1-2 for Shift "D." he admitted he was involved in activities l 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 accordance with the approved plant procedure;

2. Failure to properly review and approve the results of leak rate surveillance test requirements;

3. Failure to ensure that all leak rate surveillance test resul.ts were properly recorded in the CRO's Log;

4. Failure to take or direct the required follow-up action when the limiting.

conditions for operation specified in the THI-2 Technical Specifications were exceeded; '

5. Personally throwing away or directing his CRO's to throw away leak rate test results which exceeded the limits of the THI-2 Technical Specifications. -

Despite these actions. Mr. Miller dentes that he was involved in or was knowledgeable of other ac'tions on the part of his CR0's to intentionally influence or manipulate the outcome of leak rate test results. The weight of available evidence. including statements by one of his CRO's. Mr. Mark Coleman, and the technical analysis, strongly suggests that Mr. Miller was either not truthful in answering questions regarding his knowledge of these activities or he was grcssly negligent in his duties as Shift Foreman with respect to leak rate survalliance tests. ~

• ~ ~

~~

. $. ~5aselispon Ne' testimony of the l majority of CR0s and other Shift Foremen interviewed to date, it is clear that management's, standards for procedural compliance were lax and permissive.

In my opinion, this was created through negligence on the part of management.

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 that motivated some operators to falsify leak rate test results. In this case, contrary to Mr.

Miller's dental. I believe that Mr. Miller was wrsonally responsible for the gressure on operators to produce acceptable lea c rate test results. His bottom line" attitude, discarding of tests, admission of his knowledge of required actions for exceeding limits and his desire to avoid initiating the emergency plan or a plant shutdown are strong evidence of his personal involvement in improper activities. I also believe manipulation of leak rate l

\

tests occurred on his shift with his knowledge.

h 14.v. Mr u411 s e wens ( I

- h4e nd + .-ie..t.e- an e nna .e, s 84.

n dutteh and responsd bilities for conducting safe operations tt TM!-2 and that

...........he is ccmittw to'fd11 sing" app oved prettdurer 1tna yetattptes 1weersary to -

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. OFFICIAL RECORD COPY _

W u.s.eaa ms-eco-an

g gr a aiisimir W h SeptemberY. 19E.

f carry out those responsibilities. I also believe that he imparts this sana sense of responsibility to his subordinates.

I recomend that enforcement action -not be taken against Mr'. Miller at this time. Rather, I recomend that he be placed in a probationary status until the expiration date of his current SRO license (September 1,1986). The renewal of Mr. Miller's license at that time would be dependent upon continued satisfactory perfonnance during the probationary period.

Cri;: . . .

?;t ' -

~

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

Enclosures:

As stated cc: 8. Hayes K. Christopher i

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meno se acuoa4o OFFICIAL RECORD COPY

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• 8" " "'

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

ongoing 01 investigation. This enclosure may not be disseminated

! outside the NRC without coordination with NRR and the gemission of the E00 or the Director. 01. Internal access ar.d distribution should be on a "need to know" basis.

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

Background

I.

On June 5,1985, a.doint Office of Investigations (01)/ Office of Nuclear Reactor Regulation (NRR) interview of Adam W. Miller was held in the Three l

Mile Island Training Facility, Middletown, Pennsylvania. The purpose of the i

interview was to determine Mr. Miller's role if any, in, improper activities ,

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

i

- 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. Miller at the interview were his personal attorneys Mr.

Smith B. Ge Harrisburg,phart Pennsylvania. and Ms. Jane A copy G. Penny of the of transcript the law fim of Mr. Killian & Gephart, Miller's interviv i

is included as Attachment 1 to this enclosure.

Mr. Miller is employed by General Public Utilities Nuclear Corporation (GpVN) and currently holds the position of Manager Plant Operations TMI-2 and is a i

licensed Senior Reactor Operator (SRO) on TMI-2.- Mr. Miller started with Metropolitan-Edison Company (Met-Ed) in April 1973 as an Auxiliary Operator i

(AO). He served in that capacity for a promoted to Control Room Operator (CRO)pproximately .

Mr. Miller served two as years before being an on-shift CR0 at TMI-2 from mid-1975 to mid-1978 at which time he was promoted to Shift 1 -

Foreman. He remained in that position at TMI-2 until the Fall of 1979 at which time he was transferred to the Training Department as an instructor.

In the Spring of 1981, he was transferred back to the Operations Department as a Technical Analyst, serving as the assistant to the Manager Plant Operations TMI-2. Mr. Miller was proacted to his present position in the sumer of 1983. As Manager Plant Operations TMI-2, Mr. Miller has four Group Managers who report to him: Chemistry Radweste Operations Radwaste Support.

. and Plant Operations. Mr. Miller repo,rts directly to the site Operations Director.

The interview with Mr. Miller concentrated on the wriod September 30, 1978-

! through March 28, 1979. During this time period, at served as the Shif t Foreman of shift "D" at TMI-2.

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

l Miller is provided in Section II of this enclosure. A sumary of the interview with Mr. Miller is provided asSection III. The sumary of

' interview section includes citations to the page numbers of the transcript from with the sumarized infomation was extracted. Overall findings and conclusions regarding Mr. Miller's involvement in improper activities 4

associated with THI-2 leak rate surveillance testing are presented in Section .

IV of this enclosure.

i l .

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II. Sumary of the Technical Analysis In late 1983 and early 1984, a technical analysis of the leak rate surveillance tests conducted during the last six months of operation of TMI-2 was perfomed by the NRC. This analysis was done as technical support to the l

DepartmentofJustice(DOJ)initscriminalproceedingagainstMet-Ed. In 1985. NRR performed a reevaluation of that analysis by factoring in -

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

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

during' his interview and the basis for the findings andconclusions shown in Section IV.

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

' would be signed by the operator performing the test and approved by att SRO.

' ~' In most cases, the Shift Foreman approved tests run on his shift. The test records show that of the 161 leak rate surveillance tests retained by the licensee during the period under investigation. Mr. Miller was involved in 25 leak rate surveillance tests. The table below shows a breakdown of the overall conclusions regarding these tests.

1 Breakdown of Leak Rate Tests Acoroved by A. W. Miller Evaluation Category Number of Tests 1

Total number of tests on fi1e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Tests with no apparent problems....................

) Uns tabl e plant condi tions. . . . . . . . . . . . . . . . . . . . . . . . .................

. . . . . . . . . . . . . . . .1 . 7 t Unstable or out-of-service makeup tank (MUT) level transmitter..... 5 l

Water additions to MUT (not included in the calculation)........... 2 Water additions to MUT (partially included in the calculation).....11 '

. Feed and bleed operations (not included in the calcula Hydrogen add i tions to MUT. . . . . . . . . . . . . . . . . . . . .... . . . . . . . . tion) . . . . . . . . 2 Unidenti fied lea kage greater than 1 gpm. . . . . . . . . . . . . . . . . .......... . . . . . . . . . 10 Note: Four tests fall into more than one evaluation category.  !

Test #50 contains a water addition that was not included in the calculation and was run with an unstable MUT level transmitter providing input to the computer.

Test #70 was conducted during unstable plant conditions and was i

also run with an unstable MUT level transmitter providing input l to the computer.

1 i

Tests #132 & #141 were begun during feed and bleed operations and also contains water additions that were not fully accounted for in the calculation.

i As can be seen from the table above, only seven of the 25 tests involving Mr.

Miller appear to have been conducted in accordance with the requirements and 3

i j precautions of the surveillance procedure governing the conduct of leak rate '

tests (SP 2301-301). The result of one test exceeded the limits of the technical specifications and the remaining 17 tests involve actions that '

I violate the limits and precautions of the procedure, thus yielding l questionable or invalid results. For some tests, these actions may have been

i

, ., 3 taken deliberately in a*n attempt to manipulate or influence the outcome of the test results. The basis for the evaluation of each test is presented below.

The seven tests that appear to have been conducted in accordance with the l surveillance procedure are tests #1 (09/30/78). #38 (11/06/78). #54 i

{ (12/10/78) #57 (12/11/78). #60 (12/13/78), #88 (01/06/79) and #156 l t

(03/28/79). Test #156 was actually performed by Shift "A" just p~rior to the l j accident but was signed later by Mr. Miller . ,

Onetest.#70(12/21/78), was perfomed during a period when the plant was i not in a steady state condition. SP 2301-301 directs that the test be i j performed once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady state operation when in Modes 1

through 4. The procedure cautions the operator to maintain the RCS and -

makeup system in a steady state condition during the test by avoiding. change in valve line-ups, coolers-in-service, pumps-in-service etc. power level

changes should be minimized and the operator should avoid additions or

removal of water from the RCS and makeup system during the test. For the

~

most accurate determination of RCS leak rate, the initial and final -

. conditions of reactor power RCS temperature, pressure and pressurizer level j

should be identical. Test #70 was terformed during a plant heat-up prior to criticality. The MUT strip chart stows significant oscillations during the .

i one hour test period. As will be discussed below, an unstable MUT leve' i transmitter was also used during the test to provide input to the plant computer.

i 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 l 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 l feeding the strip chart recorder and the plant computer. When the selector-i switch is tositioned 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 l

• for leak rate test calculations. When the selector switch was changed to LT-2, the opposite would occur. .

Between October 30 and November 6.1978, operators experienced problems with i both level transmitters. At various times during this period the level l transmitters were reading radically different levels in the MUT and both were l taken out-of-service for maintenance work and recalibration. During this l period, tests #33 (11/02/78) and #35 (11/03/78) were performed by Shift "D" operators and approved by Mr. Miller. During test #33 the level transmitter providing input to the plant computer was reading approximately 14 to 15 inches higher than the level recorder providing <nput to the strip chart

, recorder. According to the strip chart. MUT level decreased 3 inches or 90 gallons during the test, the level transmitter providing input to the plant ,

computer reflected only a .5 inch or 15 gallon decrease during the same period. During test #35. the MUT level transmitter providing level input to the computer was out-of-service and was pegged high at 99 inches.

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 ,

perfomed with the use of LT-1 providing input to the computer must be I

j .

considered questionable or invalid.

Of the 50 tests conducted by all shifts during this period only 16 were performed with the stable level transmitter (LT-2) providing input to the computer during the test. During this period Mr. Miller approved seven tests; four were run with LT-2 and three were run  !

i

with LT-1 providing (input to the computer. The four tests using LT-2 were j #54 using tests (12/10/78)LT-1 were: #57 12/11/78). #60 (12/13/78) and #88 (01/06/79). The three l

1. 50 (12/08/78) #66 (12/17/78) and #70 (12/21/78).

For test #50, there does not appear to be a large difference between LT-1 and i

LT-2 LT-1 mayfor not thehave initial and final produced values error.

a significant of MUT 1evel and therefore the use o test #50 also contains a possible unaccounted for water addition.As will be discus For tests

$66 and #70 rendering thethere are tests large differences between the outputs of LT-1 and LT-2 invalid.

The Shift Forsman's Log. maintained by Mr.

i Miller, records the completion of two additional leak rate tests during this period: 1045 on 12/03/78 and 1800 on 12/09

~ were retained for these tests; however, a r/78. eviewNoofsurveillance the MUT strip test sheets chart i

during these times indicates both of these tests were also run with unstable LT-1 providing input to the plant computer.

i During the entire period of time LT-1 was essentially "out-of-comission."

all six shifts including Mr. Miller's, continued to run leak rate tests (34 out of 50) with LT-1 providing MUT level indication to the computer These i

actions resulted in a meaning ess calculation of unidentified leakage that j

could not demonstrate conformance with the technical specification limit of 1 gpm.

i Two tests f50 (12/08/78) and #144 (03/10/79)include possible water

! additions to the MUT that were not accounted for in the leak rate test calculation. In addition to using unstable LT-1 as input to the computer for test #50, from the offset in the MUT strip chart it also appears that approximately 60 gallons of water may have been added to tse RCS near the -

beginning of the test. There is no log entry in the CR0's Log and no water addition is included in the leak rate calculation. Test #144 contains a possible jogged water addition to the MUT of approximately 100 gallons. There is no log entry in the CR0's Log and no water addition is included in the leak rate calculation. A jogged water addition is when water is added to the MUT in small increments over a period of time rather than adding water in a single large or batch addition. According to former Shift "E" CR0 Harold Hartman, jogged water additions were one of the methods used by by operators to manipu' ate the results of leak rate tests. According to Mr.

Hartman added jogged during thewatertest. additions were made to hide the fact water was being Test #144 was actually perfonned by shift "E" operators. Messrs. Booher and Blessing and logged in the Shift Foreman's Log by the Shift "E" Foreman. Ken Moyt; however, the surveillance test sheet was signed by Mr. Miller after he relieved Mr. Moyt.

Onetest.#128(10/17/78). indicating an unidentified leak rate of 2.07 gpm.

was performed and gigned by Mr. Coleman but was not signed by Mr. Miller.

Mr. Miller was the Shift Foreman on watch at the time the test was conducted.

This test was run during a period when the plant was experiencing high leakage (gross leakage of approximately 4.5 gpm). This surveillance test was not filed with the other surveillance tests maintained by the licensee..

Instead, this tests was filed with a set of tests associated with the

submission of LER 78-62/1T on November 1,1978.

1 particular LER is discussed durin The significance of this Transcript pages 45 through 55). g the interview with Mr. Miller (See ~

i Twotests,#132(02/27/79)and#141(03/08/79) operations that were not taken into account in the leak rate calculation. e testcont test.

Test #132 was begun during a feed and bleed operation i '

approximately 122 gallons being bled from Only 162 gallons of the addition were included in the leak

s. rate however, since the water bled from the system was culation; not inclu e

Similarly, Test #141 was also begun during operation.

n eed calculation. Water bled from the system was not included in the leak i Test minutes before the end of #141 also the containstest. a 250 gallon water addition three additions that are not fully accounted e waterfor is di In order to limit the oxygen content in the RCS andsed to*prov netmaintained was positivein suction the MUT. head for the RCS makeup pumps, a hyd of the the addition operating of hydrogen band, thenotCR0 should havewould affectedadd MUT hydrog level; ho of the configuration and environment of the MUT level detection r, because, i instrumentation (dry) reference leg ofsystem at TMI-2, water the level transmitters. could collect ure in the l or " loop seal" Under couldthis conditions, the resultant indicated MUTwater level when slug hydrogen cause a temporary i i actually adding water to the tank. pressure was increased in the MUT without Thus, the addition of hydrogen at the appropriate time before the final data reading were taken (after the computer collected its initial data in a nonconservative manner I than the actual leak rate). (e.g., the ca)lculated leak rate wo i' -

r MUT, water additions to the MUT shortly befo final data set would thus have the same result as a hydrogen add operator were aware of this cause and effect relationship Ifleading an to

" instrumentation inaccuracy " (without having to know it was

" loop seal" effect described above), he could take advantage of t written.

phenomenon to manipulate test results by the last 10 minutes of a leak rate test should cause th increase 5 inches (30 gal / inch); however increase 6 inches (180 gal).in the loop seal, the indicated le including the 6 inch riseOnce in MUT the final data was read by the computer, level, the operator would enter t gallon water addition into the computer as an operator-caused . Thus, c when the computer calculated the net unident minutes). .

Mr. Mark Coleman stated during his joint 01/NR .

, I l

I near the end several leak rate tests in order to take advantage of this specifications.to help him get tests results with the limits of the technical phenomenon Coleman's admission.

As will be shown below, the technical analysis supports Mr.

While Mr. Coleman stated he could not be sure that others on his shift also manipulated test results in this manner, after reviewing they did notthe also leak userate thistest data, he stated it would be hard to believe that method.

The table below shows that_ the last 13

leak rate tests performed by Shift "D" Control Room Operators all exhibit this same characteristic. Mr. Miller a

(#137 and #142) were approved by Mr. G.pproved R. Hitz. 11 of these tests. Two tests r m uter MUT strip

~

Error Time before Test f Date 1nput Chart Produced End of Test CRO-Test CRO-Panel g3 01/11 200 gal i 240 gal 40 gal 23 mins Coleman 122 02/16 204 gal 210 gal Olson 4 gal 13 mins 01 son Coleman 129 02/25 150 gal 200 gal 50 al 4 mins

131 02/26 154 gal Coleman Olson 180 gal 26 al 17 mins Coleman i 132 02/27 162 gal 210 gal Olson

- 48 al 20 mins Coleman Colem'an

133 02/28 100 gal 150 gal 50 al 4 mins Olson i 137 03/03 152 gal 200 gal Wright 48 gal 3 mins 01 son 01 son 138 03/04 238 gal 270 gal ' 32 gal 2 mins 139 03/05 128 gal Coleman Coleman 310 gal 182 gal 10 mins Olson 140 03/06 180 gal 01 son 210 gal 30 gal 1 min Wright ,

Olson

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' 141 03/08 228 gal 250 gal 22 gal ,3 mins 142 03/09 181 gal 240 gal 01 son Wright i

59 gal 3 mins Wright Olson 146 03/13 305 cal 330 cal 25 cal 5 mins Olson Coleman Key: Computer in put = amount of water included in test calculation by CRO.

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

i Brror Produced = difference between MUT Strip Chart and Computer Input.

j 'ime Before End of Test = time before end of test that water additioh i was duringmade the or time of last water addition if more than one occurred test.

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

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

As stated earlier in this section, SP 2301-301 cautioned the operators to

' avoid the addition and removal r,f water from the reactor coolant and makeup systems during leak rate tests. A review of all leak rate tests, during the period under <

nyestigation, show that this pattern of "underrecorded water additions" near the end of the leak rate test is unique to Shift "D." Five -

other tests are also classified as underrecorded water additions; however, these tests were done by three different shifts and only two show that the water additions were riade during the last 10 minutes of the test.

During interviews with the three CR0s on Shift "D." three different explanations were offered for why the water additions were made. As stated above, Mr. Coleman said water additions were made with the intent of influencing the outcome of the test by taking advantage of the MUT level instrument error. ' l

he said he was not aware of this phenomenon owever, Despite the de procedural cautions not to add water during the test, Mr. Wright added MUT water nearthethe to approximately same end level ofasthe existed testatintheorder est.

start ofto the i

Wright technique.said he believed calibration errors could be minimized by g this tests involving While Mr.the initial Wright were and within final twovalues inches (60 of MUT gallons) level for

{ -

, Mr. Wright was different from the MUT strip chart value.could not ex

- Mr. Olson could not recall why the water was added, but assu additions were necessary to keep the MUT level in thee norma or they were required to move control rods from their outer limit.

A review i of the not tests during approached shows anythat of thethe13 tests. lower end of the operating band f ,

other hand could be a legitimate explanation; however, since five shifts were operating the plant under the same conditionssame and with

control rod limits, shifts. This is not the case. such a pattern should also be present for the other i

In addition to Mr. Hartman five of the 13 operators interviewed i

including during Messrs.

leak rate tests. Coleman and Wright have admitted adding .

level indication and consequently leak rate test results.Colema Wright while admitting adding hydrogen during tests, stated he added hydrog ensure the hydrogen overpressure at the beginning and end of the te

the same calculation. in order to minimized instrumer.tation errors In light of these admissions by two of the Shift "D" operators, the N i

! evaluation additions amongoftheleaktestsrate tests approved by shouldMr. Miller.have identified at least so

• Miller's test. tests show definite indications of hydrogen being added There are several possible explanations for this occurrence. First, only the a small pertion of the leak rate tests that were run licensee, were ret

!. Second, the effect hydrogen additions would have on leak rate tests were subject to several variables including:

I water hydrogen inadde.i the instrumentation lines to cause a loop seal; the amount ofthe p test hydrogen w;as added.the rate of the addition; and the time before the end o Third, because their are two separate level 1

two level trans:nitters differently (i.e., the LT provi  ;

may not be influenced). computer may be affected while the LT providin In susenar

, March 28,y, the technical analysis shows that between September 30, 1978 and 1979,18 of the 25 tests 721 involving Mr. Miller included i

actions that were contrary to the pr(ecau)tions, limitations and of Surveillance Procedure 2301-301.

{

! results greater than the technical specification limitThese actions included: approving tests

! conducted during unstable plant conditions or with an u;nstable or i

out of-comission sensor providing input to the plant computer; and a tests containing feed and bleed operations or water additions that were noi properly accounted for in the leak rate test calculation. During the last .

I

. three months of operation, where identified leakage was high and s i

1 i

_ _ _ _ _ _ __ _ _.--__..- __ ___ _ _ _ _-o,-s _----nym,. _ ,,-,

, . 8-leak rate these tests were more difficult to obtain,12 out of 14 (86t) exhibited characteristics. Based upon the high number of questionable or invali-tests it appears that the tests were accepted as valid as long as the results were evolutions less than during in progress the technical the tests. specification limit, regardless of the In some cases, these' evolutions were results.performed with the intent of wrongfully influencing leak rate test III. Interview Sumary '

During the period under investigation. September 30, 1978 through March 28, 1979. Mr.toMiller assigned Shift indicated "D." that he was a Shift Foremen at THI-2. primarily The licensed members of his shift included: Shift Supervisor Greg Hitz, and CR0s Dennis Olson. Mark Coleman and Lynn Wright. i l

The CR0s the Shift reported directly to Mr. Miller and Mr. Miller reported directly to Supervisor. l and TMI-2 and ran the shift for both units.The See pages Shift5 Supervisor

& 6. was cross-licen '

- Prior to relieving the shift. the Mr. Miller would receive a briefing froni the off-going off-going CR0s. Shift Foreman and the CR0s would receive a turnover from the Depending upon what evolutions were scheduled during the shift there would be a short meeting with the Shift Supervisor. Shift Foreman. CR0s and at least some of the A0s to discuss what had occurr the previous their shift. shift and to assure that everyone knew what to expect during Mr. Miller stated that he could not recall any specific issue related to the meetings. foe performance pages 7 8 8. of leak rate tests being discussed during those where leak rate problems were discussed.Mr. Miller also did not recall He did not remember receiving any written correspondence or instructions from the Supervisor of Operations, or any higher level of management. pertaining to problems associated with getting acceptable leak rate surveillance tests or associated with management leveltest rate decisions procedure. related to correcting any procedural problems with the leak Se_e,pages B & 9.

According shift. As to Mr. Miller, the Shift Supervisor was the lead person on the '

shift., a result. Mr. Hitz had a large part in moving things along on the Mr. Hitz would not physically watch what Operators ware doing; however, he objectives were would met. set the objectives for the shift and assure that those Since Unit I had been in operation for quite sometime.

Mr.

page 9.Miller stated that Mr. Hitz spent the majority of his time at Unit 2. See e Mr. Miller stated that the policy for shift activities. including approval of evolutions was set by the Supervisor of Operations. Mr. James Floyd. Mr.

Miller was, asked to describe Mr. Floyd's approach towards managing the Operations Department, particularly in ter:ns of what he expected from his supervisors and other plant andevolutions.

operators in terms of carrying out surveillance requirements Mr. Miller stated that Mr. Floyd was very knowledgeable about the proper operation of the plant and how operation was related to safety; however. "he had a tendency to let paperwork type things pile up and sort of get shuffled to the side." Mr. Miller agreed that in general, the attitude of " don't worry about the paperwork, just keep the hardware operating" was imparted to the operators. See pages 10-12. ,

- - . - . _ _ , , . . _ . - , _. _ - _ . _ g -------- . - . , - . .

In addition to the Supervisor of Operations. Mr. Miller was asked to describe his interface with other management personnel, such as the Superintendent of i Technical Support (Jim Seelinger until December 1978 and then George Kunder).  !

or the TMI-2 Plant Manager (Joe Logan). Miller did not recall much contact i with Mr. Seelinger. He stated that he associated him mainly with TMI-1. He also did not have occasion to interface directly with Joe Logan. He stated that Mr. Logan was new to TMI. As a result. Logan was splitting his time '

between his job as Plant Manager and the training program to become licensed on Unit 2. Miller did not think he could do both tasks properly and I therefore, Miller did not believe that Logan every really "got up to speed" on the actual o George Kunder. peration of the unit prior to the accident. With respect to Miller stated that Kunder was such more aware of all the operations associated with the unit than either Logan or Seelinger.

Mr. Miller could not recall any particular suggestions, directions or ~

recomendations that he received from any of these individuals that may have-impacted 12-15.

on the way leak rate surveillance tests were perfomed. See pages

- After reviewing copies of TMI-2 Technical Specification 3/4.4.6.2. " Reactor Coolant System Operational Leakage." and Surveillance Procedure 2301-301

" Reactor Coolant System Inventory." Mr. Miller was asked to describe how leak rate tests were performed in 1978/1979 at TMI-2. ~ Mr. Miller stated that first the operator would check the status of the plant. If it'was relatively stable, the operator would go to the plant computer and input the required command to start the test. The computer would then print a series of questions including the desired time interval that the leak rate test would be run. This was usually one hour. Once the operator answered the questions, the test would begin and the initial set of data would be taken by the computer. After one hour, the computer would obtain its final set of data and again ask a series of questions including whether there were any l operator-caused changes, such as water additions. After responding to the

questions, the computer would print out the initial and final values of key plant parameters and. the leakage values (e.g., gross leak rate, total identified leak rate and net unidentified leak rate). See page 16.

~

With three CR0s on watch, the panel operator would not usually be the individual conducting the leak rate test; however, he would normally be infomed that the test was being conducted by the operator running the test.

If water additions were made to the MUT.'the panel operator would nomally be the one to make these additions. While this was the general practice, any of the operators could run the test or make the water additions. In order to e properly compute leak rate, any water added to the MUT had to be accounted for prior to the computer performing its final calculations. If a water addition was made. Mr. Miller stated that the amount of the addition would be obtained from the batch controller. He recalled that the batch controller -

was very accurate. If the batch controller was already reset to zero, the operator performing the test would either ask the operator who made the addition for the total or he could look in the CR0's Log. Generally all log entries were made by the panel operator. See pages 17-19.

l

' Mr. Miller recalled even though the technical specifications required that a leak rate test be run at least once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, he recalled that they were actually run every shift. The operators did not need to be directed to perform the test; it was part of their shift routine. Because the tests were run much more frequently than were required, they were not considered a

I

, surveillance test per se.

allowable limits of the technical specification, it would be co valid test and the next test would not be required for another 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />.If the test did not meet the requirements of the technical specifications, it was not considered a surveillance test as long as they had not exceed the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> window since the last good test. See pages Ig-21.

Mr. Miller did not recall how that interpretation of the technical specification came into existence.

He recalled it being a fairly comon understanding in the Operations Department that had existed for years. While he did not know who in management know of this practice, he stated he would be surprised if people like Jim Floyd and George Kunder were not aware of the practice.

i He did not know if other managers such as Jim Seelinger or Gary Miller (Station Manager) would be aware of this practice; however. since the met quite often with the Shift Supervisors, he believed they would have plenty of opportunity to be aware of it. See pages 20-24.

As best he could recall. Mr. Miller did not remember any other surveillance tests being treated in this manner. He believe that leak rate tests were treated technical differently specification because they were considered a routine task rather than a surveillance.

Mr. Miller stated that other methods were used by the operators to check for leakage in the RCS such as containment particulate monitors and containment sump inventory and discharge; however, the inventory balance test was the only method that coui.

be used to quantify leakage. See pages 24 & 25.

When asked if he thought the leak rate test was a valid indicator of leakage, he could recall some question in his mind about about the tolerance associated with the calculated number however, between activities associated with startup, testing and early consner;cial operation coupled with his that the test was a vary routine task, he never really pursued the issue. He See recall did their pages 25 being a considerable assount of variability in test results.

& 26s Tests results essentially that exceeded the unidentified leakage limit of I gpm were ignored.

He could not recall specific examples of his operators bringing him test results that exceeded the technical specifications, but he l

i believed that it occurred. He stated that if that did happen, he would have probably bad one. given the operator instructions to run another test and discard the He did not remember discussing this practice with his Shift I Supervisor, but believed whatever he did was probably very consistent with what Mr. Hitz would have done. Mr. Miller could not recall any of the operators on his crew expressing concern about the way leak rate surveillances were being handled. See pages 27 & 28.

In reviewing leak rate tests, Mr. Miller believes he may have given them a very cursory look before signing his approval. He felt that he may have essentially just looked at the bottom line numbers and nothing else. As long as it did not exceed the technical specification, he would approve it. If it exceeded the technical specification, he would throw it away and have the

. operators run another test.

paperwork near the end of his Heshift.

recalled that he reviewed most of the He had several things, in addition to leak rate tests, that required his review, including: Shift and Daily Checks, the Logs.

CR0's Log the normal hourly log readings and about four or five A0s' See pages 28-30.

Mr. Miller was advised, that Mr. Olson had testified that after an incident in October 1978 (Note: this incident will be discussed later), he never threw 1

l away a bad leak rate. Olson said he would run another test or tests until he  !

got a good result and then submit the results to his Shift Foreman as a package (e.g., good test on top with the bad tests stapled to it). Mr.

Miller did not remember Mr. Olson doing that. Mr. Miller was also informed that Mr. Coleman testified once he had turned in a leak rate test greater than 1 gpm to his Shift Foreman and that when the Foreman showed it to his Shift Supervisor, he received a very negative reaction. Mr. Coleman said it was results. clear from that incident, that his Supervisor only wanted to see good Mr.' Miller did not recall such an incident. He did recall seeing tests that exceeded the technical specification and he would consider them invalid. The only reason for considering them invalid was because they exceeded the technical specification limit. There was no conscious rationalization applied, that was just the pra'ctice. Note: Leak rate test 128, performed by Mr. Coleman, exceeded the technical specification limit and I

was retained by the licensee but not signed by Mr. Miller. he pages 30-37.

Mr. Miller agreed that the technical specifications are related to safety and that as a Shift Foreman, it was his responsibility to ensure compliance with the technical specifications. He also agreed that since the leak rate surveillance test was the only method to quantify the amount of leakage, it was the only method that could be utilized to shown compliance with the '

technical specifications for leakage. He was then asked if he received a test result that indicated unidentified leakage was greater than I gpm, how he would know that leakage was not greater than the limit. Mr. Miller stated: "Looking back on it today, there is no way. I don't know." See pages 37 & 38.

Mr. Miller was asked if he had any reason to conclude that plant management had made a conscious decision to ignore the surveillance test in order to keep the plant operating rather than having to enter the action statement and -

possibly shutdown the plant. Mr. Miller stated that the only information he was aware of along that line was a quote he recalled hearing during the Grand Jury investigation to the effect that Mr. Floyd considered the leak rate tests that were filed just as invalid as the ones that weren't filed." From that Mr. Miller assumed that Floyd considered the leak rate tests useless.

But he could not say that the tests were ignored by Floyd just to keep the plant running. Sea pages 38-40.

Mr. Miller was asked if the operators knew that Technical Specification 3.4.6.2 required that the leakage be reduced to within limits within four hours or they were required to commence shutting down, if the unidentified leakage was greater than I gpm. Mr. Miller stated that he believe that was understood. He said the way he remembered it was that the 1 gpm was not only the triggering point for entering the action statement of the technical specifications, but it was the triggering point for entering the emergency plan as ari unusual event and notifying the NRC that an action statement had been entered into. He believed that people may have tended to look the other way and ignore tests that had results greater than 1 gpm because they did not want to trigger those actions. See pages 40-45.

A copy of LER 78-62/1T along with an attached routing sheet with the typewritten names and handwritten initials of licensed operators was provided to Mr. Miller for his review. The routing sheet was used to -

indicate which individuals had seen the LER. Although Mr. Miller's initials were on the routing sheet, he did not have a preaccident recall of j the incident described in the LER. See pages 45 4 46.

g .,..- - - _, - . - - , -- - - _ _ -

. . Note: During a routine inspection of TMI-2 operations on October 18 1978, and NRC inspector discovered several bad leak rate tests lying in the control room and that THI-2 had been operating for an extended period of time with unidentified leakage exceeding the technical specification limit. The incident resulted in the submittal of Licensee Event Report (LER) 78-62/17. 1 The LER states in part: "This event was caused by a misinterpretation of the requirements of the technical specifications....The appropriati personnel will be instructed on the requirements of applicable sectier of the T.S. and the requirements to imediately invoke applicable I actions statements when the provisions of the LCOs [ limiting conditions for operation) are not met."

Mr. Miller stated that he did not recall being advised or instructed that they had been misinterpreting the technical specifications,- consequently he did not provide any revised instructions to his CR0s. Mr. Miller did not

, recall ever changing his interpretation of when the action statement should l

~

be invoked. He did not believe there were any changes made to leak rate testing practices as a result of this LER. See pages 45-50.

Mr. Miller was informed that the testimony provided by Messrs. Coleman and Wright were similar to his; however. Mr. Olson testified that he did recall the incident and that he was instructed in the proper interpretation of the requirements of the technical specifications.

Mr. Miller stated that it was possible Mr. Olson had stood watch with a different shift during his relief week and may have learned of the incident from that shift. Mr. Miller also said that if Mr. 01 son had that knowledge. Olson had not discussed it with him.

Miller did not recall Mr. Olson ever coming to him with a leak rate test greater than 1 gpm and saying to Miller that based on his interpretatior, of the technical specifications they had only four hours to identify the.

source of the leakage or else they were required to shut down. Mr. Miller did not ever 3.4.6.2. recall invoking the action statement of Technical Specification See pages 4g-51.

~

Mr. Miller was asked if at some point after this LER was issued, it was emphasized to him by his Shift Supervisor or any member of plant management to instruct his operators to ensure that they got rid of bad leak rate tests so that the NRC would not see them. Mr. Miller did not believe that was the reason unacceptable leak rate tests were thrown away. He said that they were discarded because they were not going to be doing anything with them in the future. It was something that had been going on for years. See pages 51-54.

The next portion of the interview with Mr. Miller centered around Hartman's l

allegations that leak rate tests results were manipulated by operators and that pressure was being applied to operators to get good leak rates. See page 55.

Mr. Miller stated that until about a year or two after the accident, he was not aware of discussions or of the possibility that you could add hydrogen to the MUT towards the end of the test in order to affect the leak rate test results.

He stated that he had never observed the addition of hydrogen having any effect on MUT level indiction. Mr. Miller was advised that Coleman had testified that this phenomenon was cormon knowledge among Shift Foremen and Shift Supervisors. Mr. Miller did not agree. He said that there,

i may have been some who had this knowledge, but he did not believe it was a widely known phenomenon. He said that from the discussions he had with individuals after the accident, the majority of people he talked with were as surprised as he was that hydrogen additions would have that effe:t.

He did not have any discussion with anyone who said that they knew of this phenomenon prior to the accident. Mr. Miller stated he had no personal knowledge at that time that anyone on his shift manipulated leak rate tests

with the addition of hydrogen. See pages 56-59.

Mr. Miller stated that prior to the accident he was neither aware of nor had any suspicions of the operators en his shift using any mechanism to assist them in getting good leak rate tests results. He was not aware until after the accident that adding water to the MUT could produce the same effect on

- MUT level indication as a hydrogen addition. He said when he first heard about it in 1980 or 1981, he was surprised that the effect was that pronounced. He was also surprised that Mr. Coleman had been aware of the effect and used that method to assist him in getting a. good leak rate test.

See pages 59-61.

The next portion of the interview concentrated on a detailed discussion of individual leak rate tests performed by Shift "D" and approved by Mr. Miller.

It was pointed out to Mr. Miller that compared with the other five shifts, Shift "D" had the highest percentage of questionable tests during the last three months of operation at TMI-2. This was the period when the plant experienced a large amount of identified leakage from the top of the pressurizer and taat as a result, satisfactory leak rate test results were more difficult to obtain. During this period his shift was the only shift i

that day a' fter day was able to.cbtain a satisfactory leak rate test. In almost all cases this was accomplished by the addition of water to the MUT during the last few minutes of the test, thus taking advantage of the phenomenon discussed above. It also pointed out to Mr. Miller that this was not only something that could be seen from a technical analysis of test -

results, it was also confirmed by one of his CRos-Mark Coleman. In response Mr. Miller said, "I can state with one hundred percent fact that I had no knowledge that changing -- addin

manipulate the leak rate tests."g hydrogen or adding See pages 61-67. water to the MUT would t

l Mr. Miller stated that he had reviewed all of the leak rate tests performed

by his. shift recently and he did not see any legitimate operational reason why, day after day, their shift had to add water five to ten minutes before the end of the test. Mr. Miller stated that if operators were taking advantage of instrument errors by adding water and using the number off the batch controller as the amount of the addition, knowing that the computer was going to read the water level off the MUT level instrument, they were manipulating test results. When asked if he felt that way because of the situation today, Miller responded by saying

Definitely for today's situation that is definitely the case, and as far as I remember it was just not my nature to do things like that intentionally. I would think that even back then I would have considered that manipulation.

See pages 69 & 70. -

Mr. Miller also agreed that performing a test with an instrument that is '

f .

inoperable or out-of-service to calculate a test result would also be considered manipulation and would provide a meaningless result. Mr. Miller was asked if he payed very much attention to the performance of leak rate tests. He responded by saying:

Well, like I said earlier with regard to reviewing this, it sounds like I was very -- like I wasn't doing my job very well when you focus it in on one aspect like this. I don't remember really getting too involved ever in the conduct of a leak rate test. It may have been done during the shift and I would see that the sheet -- sometimes during the shift, towards the end of the shift, it just seems to me like I was doing other things. I was out in the plant. I just don't have too much recollection on really being too involved with them.

See pages 70 & 71. -

Mr. Miller stated that his sensitivity to procedural compliance was heightened after the accident; however, he thought that prior to the accident he was more sensitive to procedural compliance than most of the other supervisory people. See pages 71 & 72.

Test #128(10/17/78) was reviewed with Mr. Miller. It was pointed out that based upon the slope of the MUT strip chart it was apparent that the plant was experiencing significant leakage. The test showed unidentified leakage of 2.07 gpm. After reviewing the data, Mr. Miller stated that looking at it today, he could see that there was no basis for considering the leak rate test invalid. See pages 73-77.

Mr. Miller was asked if during the period October 1978 through March 1979 he was aware of any trouble with the MUT level transmitters. He said that based upon his recent review of the leak rate tests, he was aware of problems with LT-1 and he assumed that he would have been aware of such problems at the time. He stated that if he was aware of such problems, he would have informed his operators not to use the inoperable' channel as an input to the computer for performing leak rate tests. Mr. Miller was shown several examples of leak rate tests performed by members of his shift, where both the unstable LT and the stable LT were used at different times to provide input to the computer. Mr. Miller agreed that test results using LT-1 could not be relied upon. See pages 77-87.

Several examples of tests involving water additions during the last few minutes of the test period were also discussed with Mr. Miller. Again, Mr.

Miller stated that he could not see why these water additions were required and he agreed that the amount of water added according to the MUT level indicator was higher than the amount logged in the CRO's Log and manually included in the test calculation by the CR0s. See pages 87-92.

After reviewing these tests, Mr. Miller stated that while it appears fairly obvious now that his operators may have been taking advantage of I

15-perturbations in the MUT level transmitters, he reiterated that he had no knowledge of these actions at the time. He had no suspicions that this was occurring on his shift or any other shift. He had no conversations with other Shift Foremen who indicated suspicion on their part that operators on their shifts were doing this type of thing. See pages 93-96.

Mr. Miller was asked, if operators were not directed by their supervisors to manipulate test results, why would they do it on their own. Mr. Miller could only speculate that it may have involved some misguided pride, competition or one-upmanshipbetweenshifts.(e.g..theymayhavefelttheycouldgetagood leak rate test on their shtft while the other shifts could not). See pages97-100. '

IV. Findings and Conclusions '

During the six months prior to the accident at TMI-2, while Mr. Miller served as Shift Foreman for Shift "D." many of the practices associated with conducting RCS leak rate surveillance tests violated approved procedures and the TMI-2 Technical Specifications. Based upon the NRR technical analysis of leak rate tests during this period coupled with the OI/NRR interviews of Mr.

Miller and the three CR0's assigned to Shift "D" (Coleman Wright and Olson),

the following findings and conclusions are drawn.

1. TMI-2 Technical Specification 4.4.6.2 required that RCS leakages be i

! demonstrated to be within limits by the performance of a RCS water inventory balance (leak rate test) at least once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady state operation. TMI-2 Technical Specification 3.4.6.2 limited unidentified leakage to I gpm. On Mr. Miller's shift leak rate tests were routinely run at least once per shift, plant conditions and evolutions permitting.

i

2. TMI Administrative Procedure 1012. " Shift Relief and Log Entries "

required the title, number, start and completion times of all periodic tests required by the technical specifications (i.e.. leak rate tests) be logged in the CRO's Log. Contrary to this requirement only

- satista: tory (i.e. unidentified. leakage less than 1 gpm) leak rate tests were legged in the CR0's Log by Shift "D" personnel.

3. Because Shift "D" performed leak rate tests more frequently than required by the technical specifications, only satisfactory tests were considered surveillance tests. Tests with results in excess of the technical specification limits were not considered surveillance tests and were discarded. This action was contrary to THI-2 Technical Specification 6.10.1.d. " Record Retention." which required that -

records of surveillance activities required by the technical specifications be retained for a period of at least 5 years. Mr.

Miller was not sure how this practice originated; however it had existed for years and was connon practice on all shifts.

4. Because leak rate tests were run so frequently.'the CR0s on Shift "D" conducted these tests on their own as part of their shift routine. If tests results exceeded the limits of the technical specifications, the CR0s frequently discarded tests on their own. If an unsatisfactory test was provided to Mr. Miller, he would personally discard the test and instruct the CR0s to perform another test.

, , . _ - - - , - _ . - . , - , , . - - _ , , , ,_m.,__ . . - . . , - -

s 5.

In reviewing before signingleak his rate tests, Mr. Miller gave them a very cursory loot soproval. He essentially just looked at the bottor line numbers. As long as the results did not exceed the technical specifications, he would approve the test.

6. '

In general, Mr. Miller believed that prior to the accident, the general attitude of " don't worry abcut the paperwork just keep the hardware operating" was imparted to the operators by the Supervisor of Operations Mr. James Floyd.

7.

Surveillance Procedure 2301-3DI, " Reactor Coolant System Inventory,"

required the operators to enter the action statement cf Technical Specification 3.4.6.2, if unidentified leakage exceeded 1 gpm. The )

action statement required leakage to be reduced within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in cold shutdown within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.

he and his CR0s were aware of these requirements at the' time.

Mr. Miller believed that Nevertheless, as long as a satisfactory leak rate test was obtained within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> of the last satisfactory test, the action statement-was not invoked, regardless of how many unsatisfactory test results l were received in the interim. This policy of accepting good tests and ignoring bad tests was also practiced by all shifts. -

8.

Mr. Miller stated that unidentified leakage of 1 gpm was not only the triggering point for entering the action statement of the technical specifications, but it also required notification to the NRC and was the triggering point for entering the Emergency Plan as an unsual event.

He believed that people may have tended to look the other way and ignore tests that had results greater than 1 gpm because they did not want to trigger those actions.

9. .

Although Mr. Miller had initialed the routing sheet for LER 78-62/1T, he did not have a preaccident recall of the incident. Contrary to statements in the LER that the event was caused by a misinterpretation of the requirements of the technical specifications and that operators would be instructed to invoke the action statement when the Itmiting condition for operation was exceeded. Mr. Miller did not recall being advised or instructed in this matter. Consequently, he neither changed his interpretation of when the action statement should be invoked nor provided any revised guidance to the operators on his shift. He did not believe there were any changes made to leak rate testing practices at TMI-2 as a result of this incident.

10.

Mr. Miller stated that he was not aware until after the accident that l adding hydrogen to the MUT towards the end of a leak rate test could affect MUT 1evel indication and consequently leak rate test results.

He disagreed with Mr. Coleman's testimony that this phenomenon was connon knowledge among Shift Foremen and Shift Supervisors. Mr Miller stated he had no personal knowledge at the time that anyone on his shift manipulated leak rate test results by the addition of hydrogen.

11.

Mr. Miller stated that he was not aware until after the accident that adding water to the MUT just prior to the end of a leak rate test O

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

l as adding hydrogen.could produce the same effect on MUT level an of the leak rate tests perfomed by his shift.After the accident. Mr. M He could not see any legitimate operational reason why, day after day, his shift had to ad wateragreed Miller to thethat MUT five if his to ten minutes operators before were taking the end advantage of ofMr.

the test.

instrument errors by adding water and using the number off the batch controller as the amount of the addition, knowing that the computer were manipulating test results.was going to read the water level 12.

After reviewing Shift "D" leak rate tests, Mr. Miller stated that while it appears fairly obvious now that his operators may have been  :

influence the outcome of leak rate tests, he stated h knowledge of this activity at the time.

i i

this was occurring on his shift or any other shift.Me had no suspicions that He had no conversations with other Shift Foremen who indicated suspicion en

_ their part that operators on their shifts were performing these actions.

13. i Mr. Miller did not believe that if operators were manipulating test results it was caused by pressure from their supervisors. He could only speculate that it may have caused by some misguided pride, competition or one-upmanship between shifts.

In sunnary, Mr. Miller agrees in retrospect that many of the actions involving leak rate surveillance testing at TMI-2 violated approved procedures and were contrary to the THI-2 Technical Specifications. plant Mr.

Miller was aware that as Shift Foreman it was his responsibility to ensure his shift's compliance with the technical specifications.

Mr. Miller also agrees that there is strong evidence, including the testimony of Mr. Coleman, to indicate operators on his shift were performing actions that were contrary to intent and/or spirit of the leak rate test surveillance procedure and that these actions were done with the intent of influencing or manipulating the outcome of leak rate surveillance tests. Nevertheless, Mr. Miller states that prior to the accident, he had little involvement in the performance of leak rate tests and had no involvement in or knowledge of operators on his shift intentionally manipulating the outcome of test results.

, The results of the technical analysis indicate that of the six shifts standing watch during the last three months of operation of TMI-2, Shift "D" had the highest percentage (935) of " questionable" leak rate tests. The vast majority of these questionable tests show water additions to the MUT during the last few minutes of the test, resulting in a calculated leak rate that was smaller than the actual leak rate. Despite conflicting testimony by the three CR0s as to why the water additions were made the weight of the evidence wo,uld indicate that these additions were ma,de to intentionally influence the outcome of leak rate surveillance tests. While Mr. Miller was not directly involved in the actual conduct of the tests and his statements that he did not order or direct the manipulation of tests are credible and are supported by the operators' testimony, it is not plausible that Mr.

Miller shift. was unaware that leak rate test manipulations were taking place on his l

_ __ --_ --- -- _ __ _ _ _ _ _ - - - ' - ~

.. .. . ..~ .. . . ..~. ... _

t '. . :. '

I NOTE: This enclosure discusses infomation that is maintained in the NRC's i Privacy Act System of Records (NRC-16). This enclosure may not be i disseminated outside the NRC without coordination with NRR and the  ;

permission of the EDO. Internal access and distribution should be on l a "need to know" basis. I l '

Enclosure 2 I. Background On June 3,1985, an interview was conducted with Mr. Adam W. Miller, a Senior Reactor Operator at Three Mile Island Nuclear Station Unit 2 in order te determine Mr. Miller's understanding of his responsibilities for the , safe operation of the plant and his comitment to those procedures and operating principles necessary to carry out those responsibilities. Participating in the interview from the NRC were Mr. William T. Russell, Acting Director.

Division of Human Factors Safety and Mr. Leonard Wiens Senior Examiner,

_ Operator Licensing Branch. Messrs. Smith 8. Gephart and James Moeller and' Ms. Jane Penny, attorneys representing Mr. Miller, were also present during the interview.

Additional background information was obtained on Mr. Miller's current performance through interviews, conducted on May 17, 1985, with TMI-2 management personnel and the NRC's Resident Inspectors for TMI-2. These interviews were conducted by Mr. William Travers Deputy Program Director.

TMI Program Office and Mr. Wiens. The personnel interviewed included:

Name Position / Title Mr. Sandy Levin Site Operations Director TMI-2 Mr. William Kelly Manager Management Services TMI-2 -

Mr. Ronald Cook Senior Resident Inspector TMI-2 Mr. Thomas Moslak Resident Inspector. TMI-2 Section II contains a sumary of the interview with Mr. Miller, and the individuals listed above.Section III provides an overall conclusion regarding Mr. Miller's current performance.

I II. Interview Sumary Mr. Miller appeared to be a cautious, conservative operator, intent on i

I ensuring that the stated actions would be in conformance with approved procedures and operating principles. Although somewhat hesitant in response to some of the hypothetical situations, overall he seemed very knowledgeable of the requirements of the operating procedures. TMI-2 Technical Specifications and facility administrative requirements. He appeared to be comitted to operating the plant in accordance with approved operating

, procedures and sound operating principles and requiring the same compliance i

from his subordinates. Overall, Mr. Miller seemed to be a highly competent, cautious, dedicated Senior Operator who would take those actions necessary to ensure that plant evolutions were conducted safely and in full compliance with plant and NRC requirements.

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111. g r.clusions No information was obtained from the interviews with Mr. Miller, concerning Mr. Miller's current pe'rformance which could be used as a basis for revocation or modification of

, Mr. Miller's Senior Operator License. His cautious approach to shift operations combined with his connitment to strict procedural compliance is a significant asset in the safe operation of the plant.

The Senior Operator Upgrade Examination used to record the results of Mr.

Miller's interview and the list of questions asked Mr. Miller along with his

. responses are included as Attachments 2 and 3. respectively.,to this enclosure.

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,1,, UNITED sTA' NUCLEAR REGULATOR

" #8 I mAsmwoTow.o, c. nosss

...* ge: 1119M MEMORANDUM FOR: Harold R. Denton, Director Office of Nuclear Reactor Regulation ,

THRU: Hugh L. Thompson, Jr., Director Division of Human Factors Safety, NRR -& pi.h' dbE1 i

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

SUBJECT:

RESULTS OF JOINT NRR/01 INVESTIGATION AND EVALUATION OF DENNIS 1. OLSON

Reference:

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

Subject:

Staff Requirements-Discussion of Pending Investigation-TMI

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

Subject:

NRR Review of O!

Investigation Materials Concerning Hartman Allegations of Falsification of Leak Rate Data at THI, Unit 2 The purpose of this memorandum is to do:vment the results of the joint 01/hRR investigation and evaluation of Mr. Dennis I. Olson, currently a Senior Reactor Operator (SRO) at Waterford Generating Station, Unit 3 and to provide a recomendation regarding whether his current SRO license should be revoked, modified, or suspended under 10 CFR 55.40 due to his involvement in ,

preaccident leak rate testing irregularities at THI-2.

Background

As a 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 those matters which required further investigation. The results of MRR's review was provided in Referen:e 2. The review detemined that follow-up investigation by 01 and further evaluation by NRR was needed in the case of l

NOTE: This memorandum and Enclosure 1 discusses information which is the subject of an ongoing 01 investigation. This memorandum and Enclosure 2 discusses information that is maintafned in the NRC's Privacy Act System of Records (NRC-16). This melerandum and enclosures may not be disseminated outside the ERC 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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seven licensed operators. Of the seven individuals identified in Reference

2. four are currently licensed at THI-2, two are licensed at Waterford 3 and one is licensed at San Onofre 2 and 3. At a follow-up Commission meeting on May 23. 1984 NRR proposed joint 01/NRR investigations and evaluations of these individuals. Subsequently. NRR issued letters to the seven individuals under 10 CFR 50.10(b) requesting additional information regarding current performance. Based upon investigation into the individuals' past involvement in improper activities at TMI-2 and an evaluation of the individuals' subsequent performance. NRR would recomend what action, if any, should be taken against the identified operators.

Past Involvement in TMI-2 Leak Rate Testing Irregularities On'the morning of November 15, 1984, a joint 01/NRR interview of l Mr. Dennis I. Olson was held in New Orleans Louisiana. The interview was-conducted under oath and in the presence of Mr. 01 son's personal attorneys.

The purpose of the interview was to determine Mr. 01 son's role in improper activities associated with RCS leak rate surveillance testing at THI-2 prior to the accident on March 28, 1979. At that time Mr. Olson was a licensed Reactor Operator (RO) and served as a Control Room Operator (CRO) on shift "D." A detailed sumary of Mr. 01 son's interview is included as Enclosure 1 to this memorandum.

Throughout the interview Mr. Olsen did not appear to answer key questions in a straightforward or candid manner. While some of his responses associated with leak rate surveillance test problems at TMI-2 were consistent with statements made to the NRC by other licensed operators, many of his responses regaroing his personal involvement in or knowlege of leak rate test ,

manipulation do not appear credible.

During the interview, Mr. Olson admitted that leak rate tests were routinely run at least once per shift although the Technical Specifications required

! the test be run only once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. At times. Mr. 01 son stated, the test had to be run several times before a satisfactory result was obtained (i.e.. unidentified leakage within the Technical Specification limit of 1 gpm). Only satisfactory leak rate test results were logged in the CR0 Log.

ged.

TestswhichexceededtheTechnicalSpecificationlimitwerenotlogShift These actions were contrary to TMI Administrative Procedure 1012 Relief and Log Entries." which required the start and stop times of all

surveillance tests to be logged in the CR0 Log.

Mr. Olson stated that prior to an incident on October 18, 1976, which resulted in the licensee submitting LER 78-62/1T. all bad leak rate test 2

results (i.e. unidentified leakage in excess of the Technical Specification limit of 1 gpm) were thrown away. Only satisfactory test results were retained. These actions were contrary to TMI-2 Technical Specification 6.10,

" Record Retention." which required that records of surveillance activities required by the Technical Specifications be retained for a period of at least five years. Following the October 18. 1978 incident, Mr. Olson stated that l

Harold R. Denton he never threw away unsatisfactory leak rate tests. He stated he would continue to rerun the test until he obtained a satisfactory result. He would then staple the bad leak rate test sheets to the good test sheet and turn it in to his Shift Foreman. However, the leak rate test records retained by the licensee include only satisfactory test results. No records of bad leak rate  !

test results were included with any of the acceptable tests. Mr. 01 son's l statement that bad leak rate tests were retained is not consistent with i statements made by other operators including Mr. Mark S. Coleman, one of _

three CRO's on Mr. 01 son's shift. Mr. 01 son's statement is also in conflict with the Department of Justice's (D0J) Statement of Facts that was read into the record as part of the criminal trial settlement (USA v. Met-Ed).

Following the October 18, 1978 incident Mr. Olson stated that he was made i

aware of the proper interpretation of Technical Specification 3.4.6.2,

" Reactor Coolant System Operational Leakage Limiting Condition for Operation." As stated earlier, the Technical Specification required that this 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 />; however, it was operating policy at TMI-2 to run the test at least once every shift. If a leak rate test were run anytime during the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> and the results showed unidentified leakage in excess of 1 gpm, the operator was required by the Technical Specification to enter the Action Statement. The Action Statement specified that leakage be reduced to within acceptable limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> 4

or the plant was to be in hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in cold shutdown within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />. Based upon a review of plant i

records, there were several occasions where Mr. Olson was on watch and leak

rate tests were likely conducted (since a valid leak rate result hao not been

! obtained for more than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />); however, no leak rate test record exists ,

for these periods. This would indicate that any leak rate tests conducted l during these periods did not meet the limits of the Technical Specifications.

Contrary to Mr. 01 son's statement that he understood the requirement of this Technical Specification following the October 18, 1978 incident, the evidence does not support that Mr. Olson complied with the requirement of the Technical Specification (i.e., entering the Action Statement when leak rate test results exceeding 1 gpm were obtained).

Mr. Olson also stated that he was unaware that hydrogen additions to the make-up tank could affect make-up tank level indication and, thus, favorably influence leak rate test results. This statement is in conflict with the statement made by Mr. Coleman, a member of Mr. 01 son's shift, who stated it was common knowledge among the CR0s on their shift that the addition of hydrogen to the make-up tank would favorably affect leak rate test results.

Mr. Olson stated that he never added water to the make-up tank for the purpose of altering leak rate test results. If water were added during a test, it was done for legitimate operational reasons and these water additions were properly compensated for in the leak rate calculation. A technical analysis of Mr. 01 son's leak rate test does not support his statement. It is apparent from the analysis that Mr. Olson was aware that l

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Harold R. Denton December 14, 1984 adding water to the make-up tank late in the test would produce the same effect on make-up tank level indication and, thus, leak rate test results as adding hydrogen late in the test. All leak rate tests performed by Mr. Olson between February 27, 1979 and the date of the accident (eight tests) include water additions during the last several minutes of the tests. Although all shifts had the same operational considerations as Shift "D," none of the other five shifts exhibited this consistent pattern of water additions just prior to completion of the test.

Current Performance On the morning of November 16, 1984, NRR conducted an interview and oral examination of Mr. Olson, currently a' Senior Reactor Operator at Waterford 3,

_ . in order to determine Mr. 01 son's understanding of his responsibilities for ~

the safe operation of the plant and his commitment to those. procedures and operating principles necessary to carry out those responsibilities.

Interviews were also conducted with Mr. Olson's supervisors on November 14 and 15, 1984. A write-up of Mr. 01 son's current performance is included as Enclosure 2 to this memorandum.

Mr. Olson appeared to be a dedicated, conscientious operator. During the interview, he was at times hesitant and somewhat uncertain as to the details of some of the Waterford administrative procedures and seemed to lack some self-confidence. However, there was nothing in his responses to indicate he could not be relied upon to operate the plant competently and reliably, or that he was not connitted to operating in accordance with approved operating 1

procedures and sound operating principles. He indicated that he believed in complete candor with respect to plant operations.

i In addition, the records of manaaement's appraisals of Mr. 01 son's performance were reviewed.

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Conclusions -

During the period Mr. Olson was licensed as a Control Room Operator at TMI-2 prior to the accident, he admitted he was involved in some activities associated with leak rate testing irregularities. However, he denies that he was involved in other actions including leak rate test sanipulation or falsification. The weight of evidence, including statements by other operators, technical analysis, and the Department of Justice's. Statement of Facts, strongly suggests that Mr. Olson was not truthful in answering questions regarding his role in leak rate test manipulation. The specific areas where Mr. 01 son's version of the facts differ from other evidence are:

1. That he never threw away unsatisfactory leak rate test results following the October 18, 1978 incident;

2. That he operated TMI-2, without violating Technical Specification 3.4.6.2, " Reactor Coolant System Operational Leakage Limiting Condition for Operation;" .

3. That he was not aware that hydrogen additions to the make-up tank could alter make-up tank level indication and consequently influence leak rate test results in a favorable manner;

4. That he was not aware that water additions to the make-up tank late in the test could produce the same effect on leak rate test results as hydrogen additions; and

5. That he never added water to the make-up tank for the purpose of -

altering leak rate test results.

While I do not believe that Mr. Olson was candid in some of his answers to questions involving his past actions at THI-2, for whatever reason, I do believe Mr. Olson does understand his duties and responsibilities for the safe operation of Waterford 3 and that he is committed to following the approved procedures and coeratino orinciples necessary to carry-out those responsibilities.

Only three of the seven operators licensed at THI-2 prior to the accident, who are undergoing a similar joint 01/NRR investigation have been interviewed. It is possible that during the remainder of these interviews additional evidence could be developed regarding Mr. 01 son's preaccident* '

activities at TMI-2 that were not considered in this report.

I reconwend that no enforcement action be taken against Mr. Olson at this time. Rather, I recormend that he be placed in a

Harold R. Denten probationary status until the expiration date of his current SRO license (November 17,1985). The renewal of Mr. 01 son's license at that time would be dependent upon a satisfactory evaluation by both the licensee and NRC of his performance during the probationary period. -

&,7 f. ~- DL Williamt. Russell.DeputyDirector Division of Human Factors Safety Office of Nuclear Reactor Regulation

Enclosures:

As stated 9

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NOTE: This enclosure discusses information which is the subject of an ongoir.g 01 investigation. This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO or the Director. 01. Internal access and distribution should be on a "need to know" basis.

Enclosure 1 -

PAST INVOLVEMENT IN TMI-2 LEAK RATE TESTING IRREGULARITIES I. Background On November 15, 1984, a joint Office of Investigations (01)/ Office of Nuclear Reactor Regulation (NRR) interview of Dennis I. Olson was held in the Federal Building, New Orleans, Louisiana. The purpose of the interview was to determine Mr. 01 son's role in improper activities associated with Reactor Coolant System (RCS) leak rate surveillance testing at Three Mile Island, Unit 2 (TMI-2) prior to the accident on March 28, 1979. Present during the interview representing the NRC were: Keith~ Christopher, Director, Office of Investigations, Region I; William Russell, Deputy Director Division of Human Factors Safety; and Robert Capra. Technical Assistant. Division of Systems ,

Integration. Representing Mr. Olson at the interview were his personal attorneys: William Marcoux of the law firm LeBoeuf. Lamb. Leiby and MacRae,  !

Washington, D.C. and Jane Penny of the law firm Killian & Gephart.

Harrisburg, Pennsylvania. Mr. Olson was placed under oath for the interview.

A copy of the transcript associated with this interview is provided as Attachment 1.

Mr. Olson is currently employed by Louisiana Power & Light Co. as a Senior Reactor Operator (SRO) at Waterford Generating Station, Unit 3. Mr. Olson has been employed at Waterford 3 since approximately May 1981. Prior to his current employment, Mr. Olson was employed by General Public Utilities (GPU) and Metropolitan Edison Company (Met-Ed). Mr. Olson was ori Met-Ed in March 1971 after serving 8 years in the U.S. Navy'ginallys Nuclear hired by .

Submarine Pro Health (NIH) gram and 11 months In Bethesda, as Mr.

Maryland. an employee at thefor Olson worked National a periodInstitute of of approximately 5 1/2 to 6 years as an Auxiliary Operator at TMI-1. He moved over to TMI-2 as a CR0 trainee when the initial set of operators were selected for THI-2. Mr. Olson received his Reactor Operator's (RO) license in June 1978 and served as a Control Room Operator (CRO) until he left TMI-2 for his current employment in May 1981.

The interview with Mr. Olson concentrated on the period September 30, 1978 through March 28, 1979. During this time period, Mr. Olson's shift consisted of the following individuals:

SHIFT "D" Shift Supervisor: Gregory Hitz Shift Foreman: Adam Miller CRO: Dennis Olson CRO: Lynn Wright CRO: Mark Coleman

, Messrs. Wright, Coleman and Olson were previously interviewed on this subject on March 28, 29 and 31, respectively, during an NRC investigation into the "Hartman Allegations." Based upon these initial screening interviews, a follow-up interview with Mr. Coleman was conducted-on April 10, 1980. A copy of the report of this latter interview of Mr. Coleman is included as Attachment 2.

A sumary of the technical analysis of the leak rate tests involving Mr. Olson is provided in Section II of this enclosure. A sumary of the  ;

interview with Mr. Olson is provided in Section III of this enclosure. The  ;

summary in Section III includes citations to the page numbers of the transcript in which the sumarized information was discussed. Overall con-clusions regarding Mr. 01 son's involvement in improper activities associated with TMI-2 leak rate surveillance testing is contained in Section IV of this enclosure. ,

II. Sumary of the Technical Analysis A technical analysis of the TMI-2 leak rate surveillance records was performed by Dr. Jin Chung of the Office of Inspection and Enforcement, Region I. This analysis was originally done as support tc the Department of Justice. The results of Dr. Chung's analysis were utilized in questioning Mr. Olson during his interview. While a more detailed sumary of the leak rate tests at THI-2 involving Mr. Olson, along with the surveillance test sheets, CR0 Log extracts, and the make-up tank MUT strip charts for the questionable tests, are provided as Attachment 3 to this enclosure, a brief sumary of the results of the technical analysis will help the reader understand the basis for the questions posed to Mr. Olson during the .

interview.

A review of the test records show that of the 156 leak rate surveillance i -

tests retained by the licensee during the period under investigation, Mr. Olson was involved in 20 of the tests. During these 20 tests Mr. Olson was either the individual who signed the surveillance test record or he was the operator on watch who signed the CR0 Log for the period during which the test was conducted. Of these 20 tests, the analysis shows that 14 tests involved possible water or hydrogen additions to the MUT during the one hour time period in which the leak rate tests were conducted. The table below shows the breakdown of water / hydrogen additions.

Tests on file involving Mr. 01 son.............. 20 Tests involving hydrogen additions.............. 1 Tests involving unrecorded water additions...... 3 Tests involving underrecorded water additions.. 10*

• Eight of these tests involve water additions during the last 10 minutes of the leak rate test. The other two tests involve water additions 23 minutes and 17 minutes prior to the end of the test.

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1 As discussed in other reports involving TMI-2 leak rate test investiga-tions, the addition of hydrogen, theoretically should not alter MUT 1evel indication; 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 leg of the level transmitters. Under this condition the resultant water slug or " loop seal" would cause a temporary increase in the indicated MUT level when hydrogen pressure was increased in l the MUT (hydrogen addition) without actually adding water to the tank. Thus, the addition of hydroger. at the appropriate time (af.ter,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 (e.g.,

the calculated leak rate would be less than the actual leak rate). Because adding water to the MUT compresses the hydrogen gas in the top of the MUT,

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water additions to the MUT shortly before the computer obtains its final data set would thus have the same effect as a hydrogen addition.

The leak rate test surveillance test procedure at TMI-2, SP-2301-3D1, cautioned the operators to avoid the addition and removal of water from the reactor coolant and make-up systems during the test. However, in the event such a change was required for operational reasons, the procedure provided a mechanism by which these changes could be accounted for in the computer calculation. Before the computer completed its calculations, a series of questions were asked of the operator performing the test. One of those questions asked the operator to enter operator-caused changes in RCS inventory.

An operator aware of the instrumentation inaccuracy (without needing to know it was caused by the " loop seal" effect described above) could manipulate test results by following the procedure exactly as written. For exangle, the addition of 150 gallons of water to the make-up tank during the last 10 minutes of the leak rate test could cause the indicated level in the MUT to increase 180 gallons. Once the final data was read by the computer l (including the 180 gallon increase in MUT level) the operator would enter the 150 gallon water addition into the computer as an operator-caused change.

Thus, when the computer calculated its value for gross leak rate and total unidentified leak rate, the leak rate result would be 0.5 gpm (30 ga11ons/60 minutes) lower than the actual leak rate.

From February 27, 1979 through the date of the accident, Mr. Olson was involved in eight leak rate tests. All eight tests show water additions were made to the MUT during the last 10 minutes of the leak rate test. In each case, the water additions were properly entered into the CR0 Log and accounted for in the computer calculation. However, in each case the amount indicated on the MUT strip chart and, thus,-the final value of MUT level recorded by the computer was significantly more than the amount entered into the CR0 Log and compensated for in the computer calculation.

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4 III. Interview Summary After being placed under oath, Mr. Olson was asked to describe his employment history prior to joining Louisiana Power & Light Co. Mr. Olson stated that he had served eight years in the U.S. Navy and 11 months employed by the National Institute of Health in Bethesda, Maryland prior to joining Met-Ed in March 1971. Mr. Olson spent approximately 51/2 to 6 years at TMI-1 working as an Auxiliary Operator (AO) prior to being assigned as a CR0 trainee at THI-2. Mr. Olson obtained his Reactor Operator's license in June 1978. See pages 3-6. During the majority of the period under investigation, Mr. Olson stated he was assigned to Shift "D." Shift "D" consisted of the following licensed individuals: .

SHIFT "D" ,

Shift Supervisor: Gregory Hitz Shift Foreman: Adam Miller CRO: Dennis Olson CRO: Lynn Wright CRO: Mark Coleman Mr. Olson stated that he did not recall being interviewed by Mr. Christopher and Mr. Martin (Region I) on the "Hartman Allegations" on March 31, 1980.

See page 8. Mr. Olson was asked to describe his association with the management structure at THI-2. Mr. Olson stated that he would see both 1

Mr. Logan (THI-2 Plant Superintendent) and Mr. Floyd (TMI-2 Supervisor of Operations) on a regular basis in the Control Room but did not recall spending any time with them discussing operational problems. He stated that as operators they also did rot interface very closely with the Shift

. Supervisor. Operational problems would normally be brought to the attention

. of their Shift Foreman. See pages 9-11.

Mr. Olson was provided a copy of TMI-2 Surveillance Procedure 2301-3D1, l

, " Reactor Coolant System Inventory" and a copy of THI-2 Technical Specification (TS) 3.4.6.2 " Reactor Coolant System Operational Leakage Limiting Condition for Operation." Mr. Olson stated that leak rate tests were routinely done by using the plant computer. The test duration was usually one hour. At the end of the test the operator would have to provide information to the computer to account for operator-induced changes to the RCS such as water additions to the MUT or pump downs of the Reactor Coolant Drain Tank (RCDT). See pages 13-14. Mr. Olson stated that the Technical Specifications required that a leak rate test be run at least once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. When a " bad" leak rate test result (i.e., unidentified leakage in excess of the Technical Specification limit of 1.0 gpm) was obtained, Mr. Olson stated he would take it to the Shift Foreman, let him know the l result, and go back and run another leak rate test. See page 14. He stated that another leak rate test was run since the TechnicaT Specification Action Statement required them to reduce the leakage to within the acceptable limits (Limiting Condition for Operation) within four hours. See page 15.

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5-NOTE: Part b of the Action Statement reads as follows:

"With any Reactor Coolant System leakage greater than any one of the above limits, excluding PRESSURE 80UhDARY LEAKAGE, reduce the leakage rate -

within limits within 4. hours or be in at least HOT STANDBY within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUT-DOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />."

Mr. Olson stated that there were times when several leak rate tests had to be

• run before a good leak rate test was obtained. He could not recall how many leak rate tests would have to be conducted on an average before a satisfactory result was obtained. See pages 15-16. When asked what was done with the bad test results, Olson saTfthey were initially thrown away.

Mr. 01 son stated that following an incident on October 18, 1978 in which an NRC inspector found several bad leak rate test results " lying around the Control Room," and the inspector questioned why the plant was not shutdown, i

Mr. Olson was given direction not to throw bad leak rate test results away.

See pages 16-18.

NOTE: The incident referred to by Mr. Olson occurred on October 18, 1978. During a routine inspection of TMI-2 operations, the inspector discovered that-TMI-2 had been operating for two or three days with unidentified leakage exceeding the Technical Specifications. The incident resulted in the sub-mittal of Licensee Event Report (LER) 78-62/1T dated November 1, 1978.

Mr. Olson stated that from that incident on, all bad leak rate tests were '

kept. He explained:

"If I was the one doing the leak rates or I was the one that took them off the computer, and there was a bad one and a good one, as best I can recall, they both got stapled together and attached to the theet and got submitted with them both on there. I know that I never threw any away after that. I can't vouch for what anybody else did." See pages 19-20.

A copy of LER 78-62/1T along with a routing sheet with the typewritten names and handwritten initials of control room personnel was provided to Mr. Gison for his review. The routing sheet was used to indicate which individuals had seen the LER. Mr. Olson confirmed that he had seen the LER before and that the initials on the routing sheet beside his typewritten name were his. See pages 21-23. LER 78-62/1T states in part:

! "This event was caused by misinterpretation of the requirements of the technical specifications. The appropriate personnel will be instructed on the requirements of applicable sections of the T.S. and the requirement to irnmediately invoke appli-cable action statements when the provisions of the LCOs (limiting cendition fer operation) are not met." See pa5e 21.

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the leak rate Technical Specification following this incident. As best he  !

1 could recall, Mr. Olson had been told the proper interpretation of the I Technical Specification. See page 26.

NOTE: Prior to this incident, the majority of operators at TMI-2 indicated that since a leak rate test was re-quired only once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, they had the full 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in which to obtain a satisfactory leak rate regardless of how many bad test results were obtained in the interim. That interpretation was the

' misunderstanding" referred to in LER 78-62/1T. ,

Mr. Olson could not recall whether from the date of the incident

_ (October 18,1978) to the date of the accident (March 28, 1979) the Action Statement of this Technical Specification had been invoked. See page 26.

When asked if it was harder to get good leak rates as the date of the accident approached Mr. Olson indicated that they were "having to add an awful lot of water towards the end" and he believed it was harder to get leak rate test results within the limits of the TS. See page 27. Mr. Olson indicated that they tried to run a leak rate test at least every shift. See page 27. He stated that when he was the individual "who put the leak rate into the cog uter " he tried to keep the other individuals on watch informed by advising them that the leak rate test was being run and to let him know if they were going to do anything that would affect the test. At the end of the test he would ask if anyone added water to or pumped-out water from the system. If they had, he stated he would enter that amount into the computer.

See page 28. .

A copy of TMI Administrative Procedure (AP) 1012, " Shift Relief and Log Entries," was shown to Mr. Olson. He was asked if this procedure required that all surveillance tests be logged in the CR0 Log. Mr.-Olson confirmed that the procedure required both the start and stop times of all surveillance tests, including leak rate tests, to be logged. However, during the period under investigation Mr.'Olson stated that only satisfactory test results l were logged. He did not recall the requirement to log the start time of all tests. When asked if all leak rate tests were not logged in an attempt to deceive anyone about how many leak rate tests were being run, Mr. Olson stated that "as far as he was concerned, it was not done to deceive anybody."

See pages 28-31.

Since Mr. Olson had stated that following the incident on October 18, 1978,

all unsatisfactory leak rate surveillance test sheets were stapled to the satisfactory test sheet. He was then asked if he knew why none of the leak rate test records that were retained by the licensee contained any unsatisfactory leak rate test records. He could not provide an explanation.

He stated:

l w -

l l

I "At the end of the day, all of the completed surveillances went in a box, and they were picked up in the morning. I guess the guy's title was just surveillance coordinator...they were taken out, reviewed and they were brought back up and put in the file."

See page 33.

Mr. Olson was asked if he had difficulty obtaining satisfactory leak rate test results. He indicated that he could not really recall. He knew he had "run a few;" however, it was not something that he " dreaded" doing every time

, he came on shift. He stated that there was no pressure on his shift to get a good test result. When asked if his Shift Foreman or Shift Supervisor ever pressured him to get a good leak rate because they were approaching the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> limit Olson responded: -

1 "I can't remember anybody saying anything like that. 'Get a good leak rate now. I want one.' No. We didn't work under that king of atmosphere." See page 35.

Mr. Olson indicated that he felt no more pressure to get a good leak rate test result than any other test. He felt it was a matter of routine. See -

page 35.

! When running the leak rate tests, Mr. Olson stated he did not have to refer l

to the procedure since .nitiating the test was a simple matter of typing the proper code into the computer. However, he stated he was familiar with the procedure including the " precautions and limitations." Mr. Olson read the portion of the procedure where it stated:

~

" Avoid addition and removal of water from the reactor coolant and make-up systems during this test. The following operations should not be conducted during the test: .

a. Make-up or chemical addition to the make-up system.

b. Sampling of the RCS or make-up system,

c. Venting or draining of the RCS or make-up filters.

d. Changing purification demineralizers or make-up filters in service.

e. Boration or deboration." See page 37.

Mr. Olson also read from another section of the procedure were it states:

"If changes to the RCS inventory must be made during the performance of this test, they must be accounted for using Data Sheet 4. Operations such as adding water to the Make-up Tank or sampling the RCS may be accounted for in this manner, however, these should be avoided if at all possible." See pages 37-38.

Mr. Olson was asked if he believed that the leakage calculations that were generated by the computer were representative of actual leakage. Mr. Olson responded saying:

"I don't know. I often thought that a leak rate was like trying to look for a needle in a haystack. I'm trying to look for one (1) . I thousand (68,000) gallon of water out of sixty-eightgallons of water and th' to do." See page 41.

Other than performing the leak rate surveillance test, Mr. Olson could not recall any other means that he utilized to determine whether plant leakage was within the Technical Specifications. See page 41. Mr. Olson indicated that he was " comfortable" with the leak rate surveillance test as it was written and implemented. He stated that he never expressed concern to any of his supervisors or other operators about the unreliability of the program.

See page 42.

Althcugh he assumed that the other operators on his shift had also thrown away bad leak rate test results Mr. Olson stated that he could not remember ever discussing problems pertaining to leak rates with any of the other operators on his shift. He further stated that he did not believe that the reason leak rate tests were thrown away was to hide them from the NRC. See pages 44-45.

In discussing hydrogen additions to the MUT, Mr. Olson stated that hydrogen was added to the reactor coolant system to scavenge oxygen. He said there was a control (toggle) switch on the panel to open the hydrogen valve to add hydrogen to the system (make-up tank). He also indicated that there was a time period at TMI-2 when hydrogen could not be added from the Control Room.

During this period, the CR0 would direct an Auxiliary Operator to perform the addition locally. See page 48. Mr. Olson claimed that he would only add -

hydrogen when it was recommended or directed by chemistry personnel. See page 48. Mr. Olson could not recall how long a typical hydrogen addition would take (e.g., he could not recall whether it took seconds or minutes).

See page 52.

Mr. Olson stated that he did not consider hydrogen additions to the MUT as

" chemical additions" that were precluded by the procedure. He was then asked if he were conducting a leak rate test and he needed to add hydrogen, would he add hydrogen while the test was being run or would he wait until the test was completed. He stated "I don't really know what I did." Mr. Olson reiterated that he only added hydrogen when chemistry. personnel told him to add it. It was pointed out to Mr. Olson that the technical analysis of the leak rate surveillance tests in which he was involved supported his statement that hydrogen was not added on a regular basis during his leak rate tests.

NOTE: The analysis shows that 20 leak rate tests involving Mr. Olson between September 30, 1978 and March 28, 1979, were retained by the licensee. Of these tests only one (February 14, 1979) indicated that hydrogen may have been added during the test. However, the hydrogen addition took place at 2130, which was the same time Mr. Olson was being relieved by Mr. Kidwell according to the CR0 Log.

Mr. Olsen acknowledged that he was aware that former THI-2 CR0 Harold Hartman had made allegations that hydrogen additions to the MUT were one of the mechanisms used by operators to manipulate leak rate test results. See page 55. When questioned about these allegations, Mr. Olson indicate rthat he had never added hydrogen to the MUT for the purpose of altering a leak rate test. He stated that he was not aware of any operators adding hydrogen for this purpose. Mr. Olson claimed that he did not have an understanding at the time that hydrogen a'dditions could affect leak rate test results or that he had ever heard from anyone that hydrogen could affect test results. See page 58. -

He was asked if Mr. Coleman or Mr. Wright ever to1d him that they manipulated test results by the use of hydrogen. He responded that he had not. However, he was aware that Mr. Coleman admitted to the NRC that he had added hydrogen for that purpose. When asked if he believed Mr. Coleman was telling the truth. Olson stated "I don't know. I have never known Mark to lie."

Mr. Olson stated that he had never talked to Mr. Coleman about hydrogen additions and that he had no knowledge at that time that Mr. Coleman may have been manipulating leak rate test results. k pages 59-60.

NOTE: In an NRC interview with Mr. Coleman on April 10, 1980, Mr. Coleman admitted that he had added hydrogen to the make-up tank in order to affect leak rate test results.

He had observed MUT level indication rise during hydro--

gen additions. Mr. Coleman stated that it was comon knowledge on his shift that the addition of hydrogen would favorably affect the test results. Mr. Coleman also stated that a hydrogen addition would only have the ,

desired result if it were added near the end of the test. Mr. Coleman also stated that there were a lot of problems obtaining acceptable test results.

Mr. Olson was then questioned on water additions. He was asked if he ever recalled a case where he added water to the make-up tank and the amount that

he added, based upon the totalizer, was different from the amount of level increase he saw on the make-up tank level indicator. Mr. Olson stated that 4I he could not really remember, but believed that was possible. See Mr. Olson indicated that if he had to add water during a leak r Fetest,pagehe62.

would log the amount in the CR0 Log and account for that amount in the computer calculation. See page 64. He stated that he was not aware of any instance where water adETEions were made and were not recorded either in the CR0 Log or included in the RCS leak rate calculations. See page 67. He stated that he was not aware of any individual operator who made unrecorded water additions for the purpose of manipulating leak rate test results. See page 67.

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The following postulated scenario was discussed with Mr. Olson.

"Let's assume for a minute that because of some problem with the makeup tank level indicator, that upon adding water to the makeup tank, it compresses the gas bubbles on the top of the tank which increases the pressure in the tank... and causes you to have a higher apparent level than you have an actual level in the tank. And if that is postulated on the order of thirty percent (30%) difference in change. That is, if one actually added a hundred (100) gallons but the makeup tank level indicator showed a hundred and thirty (130) gallon -

increase. Because of the way the computer was set up, it would automatically read the indicator off the makeup tank'.

But as the operator making the correction for the water addition which occurred during the test, if you used the number off the totalizer, you would only report that you had entered one hundred (100) gallons.

The totalizer being the more accurate indication of what water was actually added, the operator could. in his own mind, conclude that that was a proper logged entry.

But the computer would have been fooled because of the instrument inaccuracy due to the effect of the increased hydrogen pressure.

Now, that scenario that I have just described would result in an apparent thirty (30) gallon increase which was not a real ,

water addition. Thatthirty(30)pallonsovertheperiodof one (1) hour is equivalent to a ha,f a gallon per minute

~

change in the unidentified leak rate, thirty (30) divided by sixty (60) minutes.

So that if an operator were to become knowledgeable of this effect through some mechanism, a water addition that is made toward the end of the test, if that individual were to use the totalizer when the makeup tank level indicator was reading inaccurately, if you were to make a water addition, the apparent increase would be greater than the amount of water you actually added. You would have an under recorded water addition." See pages 69-71.

Mr. Olson was asked if he would consider the operator in such a situation to be more a victim of circumstances or one who was willfully atterrpting to manipulate the results. Me responded that he would consider the operator to be a victim of circumstances. See page 71. Mr. Olson stated that he did not know whether the operators knew such a situation could exist. Mr. Olson stated that he was aware of the inaccuracies between the two instruments; however, he claimed that he never tried to take advantage of the inaccuracy i

9

, - - - -,,y---.---- - - - , - , - - - . . . _ - - , . , . -

l to affect a leak rate test. See page 72. He could not recall'when he became aware of the discrepancy between the batch controller (totalizer) and what was being provided as input to the computer (MUT level indication). See page 73. ,

Mr. Olson was then provided a copy of the technical analysis of the 20 leak rate tests in which he was involved during the period September 30, 1978 and March 28, 1979. (Attachment 3 to this enclosure). After Mr. Olson reviewed the document, it was >ointed out that the analysis shows 14 of the 20 tests involve water and/or iydrogen additions during the test. All tests performed after December 17, 1978 involved some type of addition (14 tests). One test involved a hydrogen addition. Three tests involved water addi'tions which were neither recorded in the CR0 Log nor included in the computer calculation. Ten tests involved the addition of water to the MUT where the amount of water indicated on the MUT strip chart was significantly higher than either the amount logged or the amount included in the test calculation.

All ten water additions were made during the latter half of the test, with eight being made during the last ten minutes of the test. See pages 73-81.

After reviewing the data, Mr. Olson stated that he never did anything to manipulate the outcome of a leak rate test to the best of his knowledge. He was asked to explain why water had to be added on a routine basis so near the end of the test. Mr. Olson responded.

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"The only possible explanation that I can give would be in order to have to move the control rods. If they are right at the edge of the band that you are supposed to maintain." See ,

page 83.

A detailed discussion of Mr. 01 son's explanation was then pursued. This

. discussion ir.cluded a review of RCS boron concentration and control rod position at the beginning and end of his shifts to see how much control rod position and boron concentration had changed during his watch. In most cases the amount of water added during the leak rate test was in range of 150 to 200 gallons. Mr. Olson was asked if he believed a 200 gallon addition of water to the make-up tank would make a significar.t change in the boron concentration. Mr. Olson stated that the volume of the reactor coolant system was between 65,000 and 68,000 gallons and that 200 gallons isn't going to change the boron concentration any significant amount. However, Mr. Olson stated that he could not think of any other reason for the water additions.

See pages 83-88. It was also pointed out to Mr. Olson that if he needed to make these additions to control the plant it would seem that other oper m rs would also have to exhibit a similar pattern of additions. However, a review of the data indicated no other shift had exhibited such a pattern. Mr. Olson responded by saying:

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"I understand what you are saying and I understand what this shows. And it looks very incriminating. But I never did anything in that plant to affect the outcome of the leak rate.

I've got no reason to lie. I've got nothing to hide. I do-

. not cheat at my job. I never have and I never intend to. I can't explain all thtse. I really can't." See page 90.

Mr. Olson was asked if it were possible that one or both of the other individuals on shift with him could have been aware of this phenomenon and been manipulating leak rates using this method without him knowing it. he responded:

"Anything is possible. I wouldn't turn around and say, (Yeah, he did it. I didn't know anything about it it. I can't do that. I don't know that. But anything is possible. You know, my name is in the log book or my name is on the leak rate." See page 94.

It was also pointed out to Mr. Olson that in one particular test on March 3, 1979, where 150 gallons of water were added 3 minutes before the end of the test. Mr. 01 son's name appeared both on the leak rate surveillance sheet and on the CR0 Log. See page 96. The boron concentration at the beginning of the shift was 105Tppm and 1047 at the end of the shift. The controlling groups (Groups 6 and 7.) were at 93% at the start of the shift and 965 at the end. It does not appear that the rods were near the upper or lower end of the limit in either case. Water was added during the test when the water level in the MUT was in the middle of the operating band. Thus, it was pointed out that there appeared to be no technical reason for a water addition 3 minutes before the end of the test. In this particular test, tNe amount of water added according to the level increase in the MUT was 200 gallons. The amount logged in the CR0 Log was 150 gallons and the amount included in the computer calculation for leak rate determination was 152 gallons. This unaccounted for 48 gallons would lead to undercomputed leak rate for unidentified leakage of almost .8 gpm. See pages96-100.

(

l Based upon the data reviewed with Mr. Olson, he was informed that his

rationale of why water additions were made near the end of a leak rate test did not appear credible. See page 108. Mr. Russell explained to Mr. Olson that the issue of concern and the thing that regulators must rely on is the candor and the truthfulness of the reports that are made to the NRC or made to the licensee. The NRC has to be able to count on the individual doing what is right. Not coloring it to cast the blame someplace else or to.put some distance between himself and what went on but a willingness to accept responsibility for his own action. See page 107.

Mr. Olson was asked if it was possible that before February 1979 when hydrogen could be added from the Control Room, operators who were manipultting leak rate test results, used hydrogen additions to the MUT f or that reason. However, during the February / March time frame, when hydrogen

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could not be added from the Control Room, they could not use that same phenomenon so they had to go to something else like a water addition to produce the same effect. Mr. Olson acknowledged that that possibility could exist. See page 113.

Mr. Olson was asked if he had ever gotten together with the other members of his shift to discuss how they should. answer questions regarding the leak rate investigation to make sure they answered the questions the same way.

Mr. Olson stated that they had not. He also stated that he had never discussed answers to any questions with anyone from GPU. His only discussion regarding leak rate matters was with his counsel. See pa Mr. Olson also stated that he was worried about himself; therefiire,ge he116.

did not feel the need to protect anybody in GPU or any of his friends. See page 117.

_. Mr. Olson was again asked if it were possible that an individual on his sh'ift, wanting to manipulate leak rate test results, could do so without 01 son's knowledge. Mr. Olson indicated that was possible. He stated, however, that he was " amazed" when he heard about Mr. Coleman's admissions. He said he had not heard about it until a couple of weeks before this interview. See pages 117-118.

When operators were experiencing trouble getting leak rate tests, Mr. Olson was asked, what action, if any, the Operations Department was taking to correct the situation. Mr. Olson stated: '

"...when we would get a bad leak rate, Adam (Miller) would get ahold of the auxiliary operators and say, 'Go out and start walking down the lines and look at packing glands, various -

valves, you know, make-up pumps, isolation valves, anywhere you might see an indication of boron.... Which would indicate

. that you've got a leak. If it's leaking, catch it in a container for a specific time period, measure it and then we can input that as identified leakage." See pages 120-121.

With respect to the follow-up action stated in the November 1, 1978 LER regarding the need to correct computer input errors, Mr. Olson stated that there was not much that he could recall being done other than a modification to make the RCDT level input automatic instead of manual. See pages 122-123.

He stated that he was not personally concerned enough about the procedure or the computer program to make a point of discussing it with his Shift Foreman or Shift Supervisor. See pages 124-125.

The interview was concluded after approximately three hours.

IV. Conclusions l Throughout the interview Mr. Olson did not appear to answer key questions in a straightforward or candid manner. While some of his responses associated with leak rate surveillance test problems at THI-2 were consistent with

14 statements made to the NRC by other licensed operators, many of his responses regarding his personal involvement in or knowledge of leak rate test mani-pulation do not appear credible. During the interview, Mr. Olson relayed the follo.dng information: ,

1. Leak rate tests were routinely run at lease once per shift. At times the tests had to be run several times before a satisfactory result was obtained (i.e., unidentified leakage within the Technical Specification limit of 1 gpm).

2. Only satisfactory leak rate test results were logged in the CR0 Log.

Test results which exceeded the Technical-Specification limit were not logged. Note: These actions were contrary to TMI Administrative Procedure T 2, " Shift Relief and Log Entries," which required the start and stop times of all surveillance tests be logged in the CR0 Log.

" r

3. Prior to an incident on October 18, 1978, which resulted in the licensee submitting LER 78-62/1T all bad leak rate test results (i.e.,

unidentified leakage in excess of the Technical Specification limit of 1 gpm) were thrown away. Only satisfactory test results were retained.

Note: These actions were contrary to THI-2 Technical Specification T."TU, " Record Retention " which requires that records of surveillance activities required by the Technical Specifications be retained for a period of at least five years.

4. Following the October 18, 1978 incident. Mr. Olson stated that he never threw away unsatisfactory leak rate tests. Mr. Olson stated that he would rerun the test until he obtained a satisfactory result. He would then staple the bad leak rate test sheets to the good test sheet and -

turn it in to his Shift Foreman. Note

The leak rate test records

+ retained by the licensee include only satisfactory test results. No

- record of bad leak rate test results were included with any of the acceptable tests. Mr. 01 son's statement that bad leak rate tests were not thrown away following this incident is not consistent with statements made by other operators including Mr. Coleman, one of the three CR0s on Mr. 01 son's shift. Mr. 01 son's statement that bad leak rate tests were retained is also in conflict with the Department of Justice's (DOJ) Statement of Facts that was read into the record as part of the criminal trial settlement (USA v. Met-Ed).

5. Following the October 18, 1978 incident Mr. Olson stated that he was made aware of the proper interpretation of Technical Specification 3.4.6.2, " Reactor Coolant System Operational Leakage Limiting Condition for Operation." Note: While the Technical Specification required that a leak rate test be performed at least once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady state operation, it was operating policy at TMI-2 to run a leak rate test every shift. If a leak rate test was run anytime during the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> and the results showed unidentified leakage in excess of 1 gpm,

4 the operator was required by the Technical Specification to enter the Action Statement. Tne Action Statement required that leakage be reduced to within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or the plant was to be in hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in cold shutdown'within the following i 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />. Based upon a review of plant records there were several 1 occasions where Mr. Olson was on watch and leak rate tests were likely conducted (since a valid leak rate result had not been obtained for more than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />); however, no leak rate test record exists for these periods. This would indicate that any leak rate tests conducted during these periods did not meet the limits of the Technical. Specifications.

Contrary to Mr. 01 son's statement that he understood the requirement of this Technical Specification following the October 18, 1978 incident, there is no evidence that would indicate Mr. Olson complied with the requirement of the Technical Specification by entering the Action Statement when leak rate test results exceeding 1 gpm were obtained.

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6. Mr. Olson stated that he was unaware that hydrogen additions to the make-up tank could affect make-up tank level indication and, thus, favorably influence leak rate test results. Note: Mr. 01 son's statement is in conflict with the statement made by Mr. Coleman, a member of Mr. 01 son's shift, that it was comon knowledge among the CR0s on their shift that the addition of hydrogen to the make-up tank would favorably affect leak rate test results.

7. Mr. Olson stated that he never added water to the make-up tank for the purpose of altering leak rate test results. If water were added during a test, it was done for legitimate operational reasons and these water additions were proper?y compensated for in the leak rate calculation.

Note: The technical analysis of Mr. 01 son's leak rate tests does not -

support his statement. It is apparent from the analysis that Mr. Olson was aware that adding water to the make-up tank late in the test would

. produce the same effect on make-up tank level indication and, thus, leak rate test results as adding hydrogen late in the test. All leak rate tests performed by Mr. Olson between February 27, 1979 and the date of the accident (eight tests) include water additions during the last 10 minutes of the tests. Although other shifts operated TMI-2 under the same operating conditions, none of the other five shifts exhibited this consistent pattern of water additions during the last few minutes of leak rate tests.

In summary, the weight of evidence, including technical analysis, statements by other operators and the D0J's Statement of Facts, strongly '

suggests that Mr. Olson was not truthful in answering questions regarding leak rate testing irregularities at TMI-2. The specific areas were Mr. 01 son's version of the facts differ from other evidence are:

1. That he never threw away unsatisfactory leak rate test results after the October 18, 1978 incident.

2. That he operated THI-2 without violating Technical Specification 3.4.6.2, " Reactor Coolant System Operational Leakage Limiting Condition for Operation."

3. That he was not aware that hydrogen additions to the make-up tank could alter nake-up tank level indication and consequently influence leak rate test results on a favorable manner.

4. That he was not aware that water additions to the make-up tank late in the test could produce the same effect on leak rate test results as hydrogen additions.

5. That he never added water to the make-up tank for the purpose of '

altering leak rate test results. ,

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.,v., .n_,,, - - - - - - -

__ =. . - __

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NOTE: This enclosure discusses information that is maintained in the NRC's Privacy Act System of Records (NRC-16). This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO. Internal access and distrib'ution should be on a "need to know" basis.

Enclosure 2 I. Background _

On November 16, 1984, an interview was conducted with Mr. Dennis Olson, a Senior Reactor Operator at Waterford Nuclear Power Station, in order to determine Mr. 01 son's understanding of his responsibilities for the safe operation of the plant an'd his commitment to those procedures and operating principles necessary to carry out those responsibilities. Participating in the interview from the NRC were William Russell, Deputy Director, Division of Human Factors Safety and Leonard Wiens, Senior Examiner, Operator Licensing Branch. Mr. W. C. Marcoux and Ms. Jane Penny, attorneys representing Mr. Olson were also present at the interview. In addition to the interview.

with Mr. Olson, interviews were conducted with Mr. 01 son's supervisors on November 14 and 15, 1984.

Supervisors interviewed include:

Name Position / Title O. D. Hayes Operations Superintendent C. Toth Licensed Operator Training Superintendent H. Bourgeois Shift Superintendent

, Section II provides a summary of the interviews with Mr. Olson and the l supervisors identified above.Section III provides an overall conclusion t

regarding Mr. 01 son's current performance. -

II. Interview Sumary

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Mr. Olson appeared to be a dedicated, conscientious operator. During the interview, he was at tires hesitant and somewhat uncertain as to the details of some of the Waterford administrative procedures. He also seemed to lack some self-confidence. However, there was nothing in his responses to indicate he could not be relied upon to operate the plant competently and reliably, and every indication that he was committed to operating in accordance with approved operating procedures and sound operating principles.

He indicated that he believed in complete candor with respect to plant operations.

I

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2-III. Conclusion No information was obtained from the interviews with Mr. Olson concerning Mr. 01 son's current performance which could be used as a basis for revocation or sodification of Mr. 01 son's Senior Operator license. His performance durina the interview, . .

. , , support a conclusion that he would operatyina'ccordancewithapprovedoperatingprinciples.

The Senior Operator Upgrade Examination Report used to record the results of Mr. 01 son's interview is included as Attachment 1 to this enclosure, and the list of questions asked of Mr. Olson is included as .

Attachment 2.

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ap -

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.* oucg%

s Enclosure 13 i

, UNITED STATES

'! c

. NUCLEAR REGULATORY COMMISSION

,, j wAsMiscroN. o. c. nosss

• (9,g, g g ,/ January 4, 1985 j

y y is LU. 9 37 p;tt:C.;

...:.: . 2.1 3 MEMORANDUM FOR: Harold R. Denton, Directar -

Division of Human Factors Safety THRU: Hugh L. Thompson, Jr., Director Division of Human Factors Safety FROM: William T. Russell, Deputy Director Division of Human Factors Safety

SUBJECT:

RESULTS OF JOINT OI/NRR INTERVIEW WITH JOHN,J. BLESSING

Reference:

1. Memorandum from S. J. Chilk (SECY) to B. B. Hayes (01)

~ and W. J. Dircks (EDO) dated April 2,1984

Subject:

Staff Requirements-Discussion of Pending Investigation-TMI

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

Subject:

NRR Review of O!

Investigation Materials Concerning Hartman Allegations of Falsification of Leak Rate Data at TMI, Unit 2

3. Memorandum from W. T. Russell (DHFS) to H. R. Denton (NRR)datedDecember 14, 1984,

Subject:

Results of Joint NRR/01 Investigation and Evaluation of Raymond R. Booher The purpose of this memorandum is to document the results of the joint O!/NRR interview with Mr. John J. Blessing. The interview with Mr. Blessing was to confirm infomation provided earlier by Mr. Blessing that was in conflict with statements made by Mr. Raymond R. Booher during his November 15, 1984 interview with OI/NRR.- The interviews of both individuals dealt with the subjects of Reactor Coolant System (RCS) leak rate surveillance testing irregularities at TMI-2 during the period September 30, 1978 through the date of the accident, March 28, 1979 and a breach of security incident that took place at TMI-2 on July 13, 1979. During that time frame, Mr. Booher and Mr. Blessing were Control Room Operators (CR0s) at THI-2 assigned to the same shift.

NOTE: This memorandum and enclosure discuss infonnation which is the subject of ongoing O! investigations. This memorandum and enclosure may not be disseminated outside the NRC without coordination with NRR and the pemission of the EDO or the Director

01. Internal access and distribution should be on a "need to know" basis.

r ir _ 'l d } 7 Y

. . , . . , . . . . . . . . . a

t Harold R. Denton January 4, 1985

Background

As a result of a Commission meeting on March 23, 1984, NRR was' directed by Reference I to review OI investigation materials concerning falsification of RCS required which leak rate surveillance further tests at TMI-2 and refer back to investigation. 0! those provided in Reference 2. The results of NRR's review was by 01 and further evaluation by NRR was needed in the case of operators.

Waterford 3, was one of the seven individuals identified at as n additional investigation and evaluation.

oath in New Orleans, Louisiana by OI/NRR on NovemberMr. Booher was interviewed un 15, 1984. During the interview, some of the statements made by Mr. Booher did not appear credible in light of the technical evaluation of Mr. Booher's leak rate. surveillance tests and earlier statements made by both Mr. Hartman and Mr. Blessing. The results of the joint 01/NRR investigation and evaluation of Mr. Booher is

- documented in Reference 3. Because of Mr. Blessing's candid admission in April 1980 that he was involved in leak rate falsification at TMI-2, when first questioned about his involvement, it was recomended in Reference 2 that no follow-up investigation of Mr. Blessing was required. t Past Involvement in TMI-2 Leak Rate Testing Irregularities and Knowledge of the July 13. 1979 Breach of Security Incident -

On December 14, 1984, a joint OI/NRR interview with Mr. Blessing was held in the Office of Investigations Field Office, Region I. The interview was conducted by Mr. Keith Christo Region I and Mr. Robert Capra,pher, Director, Office of Investigations, Integration, NRR. Technical Assistant, Division of Systems Prior to comencement of the interview, Fr. Christopher

'while he had represented Mr. Blessing in previous interviews and =

j investigations by the NRC and the Department of Justice, he no longer j represented interview. At Mr. Blessing and would not be present at the time of the the outset of the interview, Mr. Blessing was questioned Y concerning his desire to have legal counsel present during the interview. j Mr. Blessing confinned that he had dismissed the~1aw finn of Killian and .

Gephart as his counsel on the previous afternoon and stated that he wished to proceed with the interview without the benefit of legal counsel.

A complete sumary of Mr. Blessing's interview is attached as an enclosure to

this memorandum. This enclosure also includes

a sumary of leak rate test data involving Mr. Blessing and Mr. Booher; a copy of the Report of Interview of Mr. Blessing's April 10, 1980 interview with IE and CIA; and a sworn statement TMI-2 on July signed 13, 1979. by Mr. Blessing regarding a breach of security incident at Mr. Blessing: The following key points were discussed by A. Leak Rate Testing 1.

Mr. Blessing had little faith in RCS leak rate test calculations which were performed by the computer to show compliance with the Technical Specifications.

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Harold R. Denton January 4, 1985 2.

Leak rate test results that were generated by the plant compute were not consistent with calculations done by hand and were not consistent building sump.with the amount of water that was pumped from the 3.

Leak rate test results were erratic and had to be r per shif t.

the date of the Leak accidentrate approached. test results were more difficult to obta 4.

result was obtained.It The acceptable t was comon practice to run leak rate tests unacceptable results were thrown away.ests were retained and the 5.

While Mr. Blessing did not start standing watch in the TMI-2 C Room until approximately one month after the October 18, 1978 incident, that resulted in the generation of LER 78-62/1T, it was Mr. Blessing's understanding that bad leak rate test results we be thrown away to assure they would not be seen by the NRC.

6.

Contrary to the comitment contained in the narrative of LER 78-62/IT, Mr. Blessing was not instructed to enter the Action i Statement of the Technical exceeded the Limiting Condition for Operation.

Specification when leak rate test re 7.

Mr. Blessing particularly stated that comunications on his shift were bad.

from his Shift Foreman and his Shift Supervisor.There was ve had a good working relationship with Mr. Bocher.he ,

6.

As a result of his poor relationship with Mr activities on watch as a CR0 trainee were sup. Booher, ervised by Mr. almost all his Hartman and not Mr. Booher.

9.

Mr. Blessing believes it was comon knowledge among operators MUT results. were being made for the purpose of alterin knowledge whether Mr. Booher was knowledgeab .

10. Mr. Blessing stated that he personally added 'nydrogen for the

(

believe it had any effect most of the time. purpose of altering

11. Mr. Blessing stated that he did not intentionally add water to the make-up tank in order to alter leak rate test results.

He could notwater for state that whether Mr. Booher or any other operators had purpose. added l

Harold R. Denton ,

January 4, 1985

12. Mr. Blessing believes that because of the poor consnunications between operators on his shift it was possible that water may have been added during a leak rate test and not been recorded in the CRO's Log or compensated 'or in the leak rate calculation.

13. Mr. Slessing also indicated that because of the large amount of water that was being adoed prior to the accident, it was possible that water could have been added inadvertently during leak rate tests.

8. Breach of Security Incident 1.

Mr. Blessing stated he was told by Mr. Booher that Mr. Neagle alleged he had sneaked onto the island on the evening of July 13, 1979 and tripped the operating, safety-related Nuclear River Pump (NRP-1A). Mr. Blessing was on watch when the incident occurred.

2.

Mr. Blessing stated that Mr. Booher infonned him of Mr. Neagle's allegations within a few days of the July 13, 1979 incident.

3. ,

Mr. Blessing was in the Control Room when Mr. Booher informed his '

Shift Supervisor, Mr. Bernie Smith, of Mr. Neagle's allegation.

4 Months after the incident when Mr. Blessing was told Mr. Booher was being investigated by the FBI concerning the pump trip incident, he asked Mr. Smith if he was aware of the investigation. Mr. Smith i

advised Mr. Blessing to keep quiet about it or Mr. Blessing would wind up being involved in the investigation.'

5.

Mr. Blessing was aware that Mr. Booher was suspended from work for 10 days following the investigation because of Mr. Booher's' failure to report Mr. Neagle's allegations to management. Since d 8 -

Mr. Blessing was present at the time Mr. Booher reported the incident to Mr. Smith, he was aware that Mr. Smith failed to come )

incident.during the investigation and admit knowledge of the forward 4 6.

As a results of Mr. Smith's silence and warning to Mr. Blessing, neither individual was interviewed during the investigation.

Conclusions During the period Mr. Blessing served as a CR0 trainee at TMI-2 on the same shift falsification.

test as Mr. Booher, he was involved in activities associated with leak rate that Mr. Booher was involved in these same activities.However, Mr. Blessin ,

stated that it would be hard to believe that Mr. Booher was not at leastWhile Mr. Bless

. knowledgeable of these practices, he had no firsthand knowledge that Mr. Booher was aware of leak rate falsificatfon occurring.

L_ _ ___ _ . - - - - - - -- ~ ~ --- ~ ~ ~ ~~ ~

- - ,. m, Harold R. Denton - 5- January 4, 1985 With respect to the breach of security incident, Mr. Blessing's sworn statement Mr. is in during Booher stated conflict his with Mr. Booher's version of the facts of the November case.

15, 1984 interview that he could not recall reporting the incfdent to either his Shift Foreman or his Shift Supervisor.

In addition, Mr. Booher stated that he was informed 'of Mr. Neagle's allegations quite a while after the July 13, 1979 incident.

This is in conflict with Mr. Blessing's statement that Mr. Booher infonned both Mr. Blessing and Mr. Smith within a few days of the incident.

In sunmary, it appears because of Mr. Blessing's status as a CR0 trainee and i

his poor working relationship with Mr. Bocher during the period under investigation, Mr. Blessing is not in a position to provide proof from firsthand knowledge that would either confirm'or deny that Mr. Booher was involved in leak rate falsification at TMI-2. However, based 6pon '

Mr,. Blessing's direct in'olvement v in the brwach of security incident it is .

apparent that Mr. Booher was not candid with investigators regarding his reporting of the incident to Mr. Bernie Smith. It is also apparent that~

Mr. Smith was knowledgeable of the investigation and participated in l

covering-up his direct involvement in the incident. !  !'i "I I =

g a William T. Russell, Deputy Director Division of Human Factors Safety Office of Nuclear: Reactor Regulation

Enclosure:

As stated

• a cc:

j B. Hayes K--Christopher, RI- - _

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i l

1 h [ f [ f DISTRIBUTION Docket Files 55-07159 Docket Files 55-06120 JAN 0 41985 TMurley, RI RMartin, RIV RCapra LWiens MEMORANDUM FOR: William T. Russell. Deputy Director WRussell -

Division of Human Factors Safety. NRR HThompson FRON: Robert A. Capra, Technical Assistant Division of Systems Integration. NRR

SUBJECT:

SLM ERY 0F JOINT 0!/NRR INTERVIEW WITH.. JOHN J. BLESSING The purpose of this memorandum is to docusant the results of the joint OI/NRR interview with Mr. John J. Blessing. The t.urpose of the interview with Mr. Blessing was to either confirm or refute statements made by Mr. Raymond.

R. Booher during his November 15, 1984 interview with OI/NRR. The interviews of both individuals dealt with the subjects of Reactor Coolant System (RCS) leak rate surveillance testing irregularities at TMI-2 during the period September 30. 1978 through the date of the accident. March 28, 1979 and a breach of security incident that took place at THI-2 on July 13. 1979.

During that time frame. Mr. Sooher and Mr. Blessing were Control Room Operators (CR0s) at TMI-2 assigned to the une shift.

The interview with Mr. Blessing was held in the Office of Investigations Field Office. Region I. The interview was conducted by Mr. Keith Christopher. Director. Office of Investigations. Region I and me. Just prior to comencement of the interview, Mr. Christopher was infomed by Mr. Bart Gephart of the law fim Killian and Gephart that while he had represented Mr. Blessing in previous interviews and investigations by the NRC and the Department of Justice, he no loager represented Mr. Blessing and would not be, present at the time of the interview. At the outset of the interview.

Mr. Blessing was questioned concerning his desire to have legal counsel

. present during the interview. Mr. Blessing confirmed that he had dismissed the law fim of Killian and Gephart as his counsel on the previous afternoon

and stated that he wished to proceed with the interview without the benefit of legal counsel. A complete sumary of his interview is provided below, s Mr. Blessing was advised that the primary purpose of the interview was to ascertain if he was aware of any infonnation that would indicate the level of involvement of Mr. Raymond R. Booher in the falsification of leak rate surveillance rate test data at TMI-2 prior to the accident on March 28, 1979.

Mr. Blessing was not placed under oath for this interview.

NOTE: This memorandum and enclosures discuss information which is the subject of an ongoing O! investigation. This memorandum and enclosures may not be disseminated outside the NRC without coordination with NRR and the pemission of the EDO or the Director.

01. Internal access and distribution should be on a "need to know" oasis.

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William T. Russell JAN 4 1985 Mr. Blessing is currently employed as an Engineering Specialist with United Energy Service in Reading, Pennsylvanta. He stated that was previously employed May 1981. with Met-Ed from October 1976 until he terminated his employment in He was a Control Room Operator (CRO) at THI-2 fres November 1978 untti May 1981; however, Mr. Blessing did not receive his Reactor Operator's license until April 1980. Consequently, during the period under investi-gation. Mr. Blessing was assfgned duties as a CR0 trainee. While he was in a trainee status, he was assigned to shift "E.*

follow 1ng indfyiduals: Shift "E" consisted of the SHIFT E *

~ Shift Supervisor: Bernfe Smith Shift Forenan: Ken Hoyt CRO: Raymond Booher CRO:

Harold Hartman CR0 Trainee: John Blessing

- Mr. Blessing was shown a copy of the " Report of Interview" of his April 10 1980 intervfew with IE and CIA. Mr. Blessing confirmed that the information contained in the report was true and correct tc the best of his knowledge (SeeEnclosure1).

Mr. Blessing stated that leak rate surveillance tests were routinely done on each shift. On many occasions, tests had to be run several times before results be meeting the acceptance criterta of the Technical Specifications could obtained.

away. Tests that did not meet the acceptance criteria were thrown He confirmed that it was his belief that leak rate tests were discarded in order to preclude the NRC from seeing leak rate tests that did

- not meet the acceptance criteria. He was asked if this policy originated as a result of the October 18, 1978 incident during which an NRC inspector found several unacceptable results lying in the control room and asked why they had not entered the Action Statement of the Technical Specifications.

Mr. Blessing stated that he did not have firsthand knowledge of the incident s

since he did not start as a CR0 trainee until November 1978; however, he believes thrown away.

that was the reason why unacceptable leak rate tests continued to be He stated that it was more difficult to get acceptable leak rate test results as the date of the accident approached. He belfeved this was due to problems with the computer pregram not properly accounting for the higher identified leakage to the pressurtter Reactor relief valves. Coolant Drain Tank (PCDT) caused by the leaking He believed there was a problem with the computer program since they were able to get satisfactory leak rate test results with u nd calculations. He did not know why the leak rate test records that were retained did not contain these hand calculations.

been thrown out once a satisfactory computer-generated leak rate test wasHe thou obtained.

6

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William T. Russell JAN 4 1985 He was asked about his interpretation of the Technical Specification associ-atedwithReactorCoolantSystem(RCS) leakage. Mr. Blessing stated that he believed they had 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> from the last good leak rate test until another leak rate test was required. He stated he did not think that the Technical Specifications required them to enter the Action Statement whenever they received a bad leak rate test result. Mr. Blessing could not recall ever being directed to enter the Action Statement by his supervisors due to unidentified leakage exceeding 1 gpm.

Mr. Blessing was asked to describe how leak rate tests were performed on shift. He stated it was a simple matter of inserting the correct cell letters into the computer. He said it was the responsibility of the individual who started the test to ensure the other members of the shift were advised a leak rate test was in progress. Mr. Blessing stated, however, that the comunications on his shift were particularly bad. He stated his shift did not work well together. There was very little downward communications from their Shift Foreman and Shift Supervisor. He said whfie he was very good friends with Mr. Hartman, including socializing and car-pooling together, neither of them got along with Mr. Socher. He stated Mr. Booher did not get along with most of the other CRos. He said Mr. Sooher was the type of individual who would "ask a lot of stupid questions" to CR0 trainees who were trying to get system checkouts from him. Consequently, people avoided Mr. Sooher and would go to someone like Mr. Hartman. He stated because of his poor working relationship with Mr. Bocher, he performed most evolutions under Mr. Hartman's direction. .

When asked about hydrogen additions to the MUT during leak rate tests,

• Mr. Blessing stated that he routinely added hydrogen in order to help get acceptable leak rate test results. He stated that this was a comon

. practice, although he did not personally witness other operators except Mr. Hartman performing these additions. He did not personally believe that hydrogen additions worked; however, he was told it would help. He stated that he could not recall ever having a discussion with Mr. Booher regarding the addition of hydrogen to the make-up tank in order to manipulate leak rate test results. He stated that he had also never personally witnessed Mr. Booher make such an addition; however, he stated based upon the fact it was comon knowledge among operators, that he could not imagine that Mr. Sooher did not know these actions were going on.

l Mr. Blessing was then shown sumary listing of leak rate tests involving a combination of Mr. Booher, Mr. Hartman and Mr. Blessing (See Enclosure 2).

It was pointed out that several of the tests involved unrecorded water In some cases it additions appeared that during times this water may leak rate have tests been were ini.e.,

" jogged" p(rogress.

small amounts of water added slowly over the test period). Mr. Blessing stated that he never i intentionally added water to the make-up tank in an effort to manipulate leak rate tests. Therefore, he could not confirm that Mr. Booher had used this method as an attempt to alter leak rates. He stated that due to the poor

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William T. Russell JAN 4 1985 comunications on their shift, it was possible that water could be added and the individual running the test was not aware of the addition. He could neither recall ever having a discussion with Mr. Booher regarding adding water to alter leak rate test results nor recall having witnessed Mr. Booher make such an addition. He stated that as the date of the accident approached, they needed to add large amounts of water each shift due to the increased leakage from the pressurizer relief valves. He stated it was quite possible that unrecorded water additions could have been made at that time.

Mr. Blessing was then questioned regarding a breach of security incident that occurred at TMI-2 on July 13, 1979. During this incident Mr. 41essing stated that he was on watch with Mr. Booher when a safety-related Nuclear River Pump (NRP-1A) trfpped for no apparent reason. Mr. Blessing stated that a few days after the incident, Mr. Sooher had told him that he had run into a former Met-Ed employee named Mr. James Neagle at a local bar. According to Mr. Blessing, Mr. Neagle used to work on their shift. Mr. Blessing was told-that Mr. Neagle had informed Mr. Bocher during their conversation at the bar that he was the individual who had caused the punp to trip. According to Blessing, Booher was informed by Mr. Neagle that he had sneaked aboard the island (TMI) by boat and had gained access to the pump house and tripped the pump. Mr. Blessing stated that Mr. Booher should infom their Shift Supervisor, Mr. Bernie Smith. Mr. Booher was apparently reluctant to tell Mr. Smith of the incident; however, Mr. Blessing stated when Mr. Smith came out of the Shift Supervisor's Office, Mr. Blessing told Booher to "go ahead and tell Bernie." Mr. Booher then informed Mr. Smith of what Mr. Neagle admitted to him. According to Mr. Blessing the incident was laughed off at the time. Mr. Blessing was not aware if Mr. Smith reported the incident or -

conducted any follow-up investigation.

. Mr. Blessing stated that several months later, he learned that Mr. Booher was being investigated by the FBI regarding the pump trip incident. Mr. Blessing stated he was concerned since he did not believe Mr. Booher had done anything wrong. He stated that he went to the Control Room to diset'ss the matter with Mr. Smith. When he asked Mr. Smith if he was aware Mr. Booher was being investigated, Mr.. Smith told Mr. 81essing not to say anything or he would wind-up being involved in the investigation. Mr. 81essing stated he was -

upset about Mr. Smith's response, since Mr. Bocher later recefved a suspension of ten working days without pay frem the company because he had failed to report Mr. Neagle's allegation to management. Mr. Blessing was concerned that Mr. Smith had not spoken-up and admitted to management that Mr. Booher did inform him of Mr. Neagle's allegation. Mr. Blessing stated that Mr. Bocher and Mr. Smith were good friends and that may have been the reason why Mr. Sooher did not tell the investigators that he had informed his

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William T. Russell 'JAN 4 1985 supervisor. Mr. Blessing was asked if he would sign a sworn statement attesting to the facts as he knew them regarding this incident. Mr. Blessing agreed. Enclosure 3 is a copy of Mr. 81essing's statement. .

Originalsigned by s ~- .. . .;;

Robert A. Capra Technical Assistant Division of Systems !ntegration Office of Nuclear Reactor Regulation

Enclosures:

~

1. Report of Interview of J. Blessing on 4/10/80

2. Sumary of Leak Rate Data

3. Sworn Statement of J. Blessing dated 12/14/84 cc: K. Christopher t

e DW/THIH2/BLE55ING ENCL anics) . p.H. .F. f. . .R.*. C...

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i ENCLOSUREI REPORT OF INTERVIEW BY IE/0IA WITH J. J. BLESSING ON APRIL 10. 1980 9

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A-la REPORT OF INTERVIEW WITH JOHN BLESSING

AS RECORDED BY R. KEITH CHRISTOPHER INVESTIGATOR -

U.S. NUCLEAR REGULATORY COMMISSION i I

' L On 4/10/80, Mr. John Blessing, a Control Room Operator with the Metropolitan Edison Company was interviewed casunencing at 0810. The interview was conducted at the Nuclear Regulatory Conunission Office at.the Three Mile .

Island Nuclear Power Station by Keith Christopher and Thomas T. Martin from .

NRC Region I and Mr. James J. Ctamings, of the Office of Inspector and Auditor, NRC Headquarters. Also present was a representative for Metropolitan

' Edison Company, Attorney at Law, Harry Glasspiegel. When asked if the aforementioned Attorney was present at his request, Mr. Blessing indicated I -

the presence of Mr. Glasspiegel was desired.

Blessing was questioned regarding the falsification of leak rate records in the Reactor Coolant Inventory Surveillance Test for 1MI #2. Blessing

denied knowing of any specific instances in which the leak rate records were intentionally falsified. R.. acknowledged that. it was common practice

! hy a large portion of the control . room operators to add. hydrogen.to the makeup tank while running the leak rate surveillance test in order to assist in getting good leak rate results (i.e. results that met technical

specification Pequirunants). At this time, Blessing did not specifically 1

I identify individuals who had actually added hydrogen to the makeup tank, but reiterated that it was consnon practice and well known to personnel at least up to the shif t foreman level of management. Blessing was also asked ~

to relate ways that he was personally awam of for falsifying leak rate test results. He responded by stating that in addition to adding hydrogen, an gperator could add water to the skaup tank without talling the. computer.

j This addition would result in an incorrect caputer calculation showing less leakage in the reactor coolant inventory which could cause the leak i

rate to fall within the technical specification requirements. Aless.ing l s. aid he was not aware of any instance where water was intentionally added to the makeup tank without telling the computer for purposes of falsifying leak rate test results. He continued with the statement that he did not feel the addition of hydrogen was a falsification of the leak rate records because it "didn't do anything to the makeup tank level." He did acknowledge that on numerous occasions he had in fact added hydrogen to the makeup tank while running the leak rate surveillance test. He indicated this was because other operators, who he said he could not identify, had told him that adding hydrogen would affect the leak rate test calculations. He l

emphasized' that on 9 out of 10 occasions the addition of hydrogen to the makeup tank did not work and there was no management indication that it was a forbidden practice to add hydrogen to the makeup tank while the reactor coolant inventory surveillance test was being run.

u 2

The second area of questioning concerned the destruction of the reactor coolant inventory sutveillance test records that failed to meet the technical specification requirements of 1 gallon per minute (GPM) for unidentified i

i leakage. During questioning, Blessing acknowledge that he routinely destroyed leak rate test records which were " bad" (i.e. did not meet technical specification i requirements) room operators.and acknowledged this was a comunon practice among the control Blessing was asked if he tes directed to destroy the bad leak rate calculations and he responsed by stating that the practice of throwing away of bad leak rate test calculations was " filtered down from the management people by shif t fortmen." Blessing said he was unable to l specifically identify any one foreman or supervisor who told him to destroy the bad leak rate calculations, and reiterated that it was more or less passed down through the ranks.

He cited what he thought was the origination-

- - .of this policy when on one occasion (date unknown) a bad leak rate calculation was left lying out in the control room. 8lessing said shortly af ter that incident he overheard two foremen (whom he could not/would not identify) talking in the control room, He said, to the best of his recollection, he heard them say that they (the foremen) didn't want the bad leak rate records laying out where the NRC could see them and then esk why they (the plant) were not shutdown.

He again stated that he could not specifically identify any one particular management individual who directed him to throw away the leskthe on rate test calculations, stating that it was just something he learned shift. '

At this time, Blessing was questioned regarding the addition of hydrogen to the makeup tank in order to get good leak rate results for the surveillance test.

He again stated that he has in the past added hydrogen to the unkeup tank and to get a good stated thatrate.

leak adding this was something he would do as a last resort He again stated he picked up this suggestion to add hydrogen from other operators but could not specify any particular individual. He indicated that he knew at least one other operator, name .

' forgotten, who added hydrogen during a leak rate test. He emphasized that l it was no secret that hydrogen was being added to the sakeup tank during ,

i the running of the reactor coolant surveillance test and it was a totally cosmon practica. He said it was his opinion supervisors and foremen were well aware of this practice. He again reiterated that 9 out of 10 times the issue. hydrogen addition did not work and therefort was not pertinent to this additionsWhen specifically asked what foreman were aware of the hydrogen i

well aware, of the hydrogen addition during the leak rate test.he stated When asked '

j about the other shift foreman and supervisors in the plant he stated it was his opinion, that because it was such common knowledge, all of the foremen i should have known about the practice. In referring to an operations department i

personnel roster he identified F. Scheiman, W. T. Conaway. C. D. Adams, A.

W. Hiller and C. L. Guthrie who art the Unit 2 Shift Foremen. Blessin 1

not provide any supportive information as a basis for this assertion. g did l

-_- -_-- - _ - _ - ____~_ - -__-- _ _ _---_ _

3 Bless'ing was then questioned about his understanding of the technical specifications that gave him 3 days (72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />) in which to get a good leak rate calculation for the reactor coolant inventory surveillance tes~t. He stated that it was his understanding that he only had to have a good leak subsequent unexplained " bad ones" during the period befor satisfactory leak rate result.

He said the had leak rate calculations were largely disregarded was not accurate. because he and the other operators felt the computer He said, particularly in the latter stages, just prior to the accident, it became harder and harder to get good leak rates, because the computer program errors made it difficult to get acceptable leak rates.

Blessing said these computer probless were relayed to Mr. Falls for correction, but no imediate corrtctive action was taken. He also stated that he felt that the computer program was wrong because the computer would show a large ,

-amount of leatage in the reactor coolant inventory and yet the sug pug which collects the leakage from the various reactor coolant system mechanisms would not come on, so that it was his opinion that there was no way that '

ansch water could be leaking from the reactor coolant system. He said these I were the primary reasons why they, as operators, disregarded the bad leak rate data.

He also stated that along with the computer calculated leak

rates, computer. he did many hand calculations and that he got "better ones" than the He also stated that he and Hal Hartman had nede quite a few of these hand calculated leak rates.

4 when the hand calculation was not a good one.He stated he could not remember a ti He continued that as the approach to the accident drew nearur it was more difficult to get good leak rates and there was increasing pressure to get them (good leak rates -

exerted. he did not specify management personnel areas or ways pressu)r.

although 1

e was i He said he felt the coguter was not picking up the increased leakage in the valves leading to the reactor coolant drain tank and for this reason it was causing bad calculations.

He said it was also his opinion that leak rate tests would fail on an average of 4 to 5 times per shift and that all of those results would have to be thrown away. -

Blessing also related at this time that it was his personal knowledge that Hal Hartman had in fact added hydrogen to the makeup tanks to get good leak rates during the reactor coolant inventory surveillance test. When questioned regarding the other operator on his shif t, Ray Booher, he stated that he i could' not say for a fact whether or not Bocher had in fact added hydrogen or water or in any other way falsified the leak rate.

l Blessinginwas exerted then order to getquestioned regarding good leak rates. management pressure that was being He stated that he did not feel there was any direct upper management pressure but there was a strong desire to keep the plant on the line and that no one wanted to be the shif t i

responsible for the plant coming down. He indicated the pressure resulted from his personal since of duty to keep the plant on the line. Again he i

stated that he did not feel the addition of hydrogen was a falsification of l

4 l

1eak rates because it did not work most of the time. At this tim'e he acknowledged that adding water to the tank would be a falsification, but stated that he would not normally add water without telling the computer.

He did indicate that this could happen for several reasons; for (1), the operator would just forget to add it to the computer. He also explained that the operator doing the leak rate test, was not responsible for inputting any water additions to the reactor and that in the dialogue between the two, it very well could happen that the operator running the computer i

program did not know the water was added. At this time Mr. Martin rhowed John Blessing a leak rate calculation for 2-2-79, which reflected that during the period of time of the leak rate test, water was added.to the makeup tank. It was noted by Blessing that the log entry was made by Ray

'; Bocher. He also acknowledged that he had in fact signed the computer calculations for the leak rate tests. He denied intentionally adding water -

- to the makasp tank without telling the computer in order to get a good leak rate. He stated that he probably did not know that Ray Bocher had added water and for that reason he punched zero (0) into the computer calculation for operator induced change. He said that normally he would tell the panel operator not to add water when the leak rate test would be run, but then on some occasions it would be forgotten. He said in all probability it was his own error that resulted in water being added without the computer being told. He again denied that he intentionally neglected to record the water addition in order to falsify the leak rate calculations. At this time Blessing was shown another leak rate calculation dated 1/13/79, which also indicated an addition of water during the leak rate test. He again stated that his only explanation for the water addition without talling the computer, was operator error. He concluded by denying the he intentionally falsified any leak rate calculations by the addition of water or by any other seans.

Blessing was then asked to of this interview; however, provide Blessing a sworn statement declined to provide regarding a swornthe details statement and the interview was terminated at 0945.

P Y ' l : w i . ~. + .: . r =-

R. K. Christopher /

O T. T. Martin

_ ENCLOSURE 2 SUPMARY OF TMI-2 LEAX RATE SURVEILLANCE DATA INVOLVING

, MR. BLESSING AND MR. 800HER BETWEEN 09/30/78-03/28/79 O

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.. LEAK RATE TESTS AT'TMI-2 INVOLVING J. J. BLESSING (09/30/7 Test No.' Date ' Start * ' Stop* Test CR0 ' Coments**

34 11/03 0626 0726 Blessing Kidwell/ No apparent problems.

0646 0746 Germer 41 11/22 0217 0317 Germer Blessing 0217 0317 No apparent problems.

63 7 12/15 1822 1922 Hartman Blessing 2220 2320 LT Switch. Possible Hydrogen at 1845. Approximately 3" chan j .

however, decayed off be end of test.

65 12/16 2004 2104 Hartman Blessing No apparent problems.

0020f 0120#

1. 12/17/78 67 12/17 1528 1628 Hartman Blessing i . 1525 1625 No apparent problems.

-72 12/22 2326 0026# Hartman Blessing No apparent problems.

2326 0026#

1. 12/23/78 96 01/30 2206 2306 Blessing Blessing No apparent problems.

2206 2306 97 7 02/02 0055 0155 Blessing j Booher 0100 water addition of 300 gal 0225 0325 Logged in CR0 log but not in-cluded in calculation, i' 127 02/21 0836 0936 Blessing Hartman No apparent problems.

1006 1106 136 7 03/02 1935 2035 Blessing Blessing 2030 jogged water addition of 0255# 0355f 60 gal. Not logged in CR0 log er included in calculation.

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1. 03/03/79 144 03/12 0132 0232 Booher Blessing 0150 jogged water addition of 0132 0232

60 gal. Not logged in CR0 log or included in calculation.

! 148 03/15 0450 0550 Bocher Blessing 0520 jogged wat6r' addition of 0445 0545

150 gal. Not logged in CR0 log or included in calculation.

• - Start /Stoo - Top entry is clock time. The second entry is MUT strip chart time that corresponds with the leak rate test clock time.

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• • - Time given in Coments section is clock time.

i  ? - Analysis results questionable.

Hydrogen additions: 1 LRTs on file involving Blessing: 12 Unrecorded water additions: 1 LRTs involving water / hydrogen:

Jogged water additions: 3 5 (42%)

(80%after01/30/79)

Questionable tests: I with Hartman

{ 3 with Scoher 1 only Blessing involved l

LEAK RATE TESTS AT TMI-2 INVOLVING R. 800HER (09/30/78-03/28/79) l Test No. Date- Start

• Stop*I Test CR0 Comments

, 4 10/02 0728 0828 Hartman Booher No apparent problems.

1258 1358 l

17 10/20 0213 0313 Booher Germer CR0 Log: 0214 Vented HUT. 0230 Added 0203 0303 18f H2 to MUT. 0308 Added more H2 -

, No effect on LRT. ,

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68 12/18 1815 1915 Morch Booher Hand calculation. No apparent problea

1815 1915 i'

75 12/25 0120 0220 Hartman Bocher No appa hnt problems, s 0120 0220 77 12/26 0249 0349 Booher Hartman 0305 H2added(2"effect) 0249 0349 0325 150 gal water addition. Not logg or included in calculation.

94 01/13 0937 1037 Hartman Booher 1000 water addition of 117 gal. Logge  ;

0957 1057 in CR0 log but not included in calcul tion.

97 7 02/02 0055 0155 Blessing Booher 0100 water addition of 300 gal. Leg:-

0225 0325

• in CR0 log but not included in calcui tion.

128 ? 02/23 1107 1207 Hartman Booher 1135 water addition of 150 gal. Logge 1237 1337 in CR0 log but not included in calcul tion. .

143 03/10 0351 0451 Hartman Bocher 0443 joceed addition of 80 cal. Not 1 0351 0451 logged in CR0 log or included in cal-

! culation.

144 03/12 0132 0232 Booher Blessing 0150 jogged addition of 60 gal. Not 0132 0232 logged in CR0 log or included in cal-culation.

1 145 03/13 0200 0300 Hartman Bocher 0230 jogged addition of 30 gal of wat 0140 0240 0250 jogged addition of 60 gal of wat Neither logged in CR0 log or included in calculation.

148 03/15 0450 0550 Booher Blessing 0520 jogged addition of 150 gal of 0445 0545 water. Not logged in CR0 log or inclu l ed in calculation.

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• Start /stop - Top entry is clock time. The second entry is MUT stip chart time that corresponds with the leak rate test clock time.

? Analysis results questionable.

Su:ary: LRTs on file involving Bocher - 12 LRTs involving water /H2 -

9 (75% overa11)(100P. for all tests after 12/2 H2 additions 2 Tests with Hartman 7 total 5 questionable Batch water additions 4 Tests with Blessing 3 total 3 questionable Jogged water additions 4

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