ML20237G500
| ML20237G500 | |
| Person / Time | |
|---|---|
| Site: | Three Mile Island  |
| Issue date: | 09/08/1986 |
| From: | Stier E GENERAL PUBLIC UTILITIES CORP., STIER, E.H. |
| To: | |
| References | |
| LRP-A-001A, LRP-A-1A, NUDOCS 8708140100 | |
| Download: ML20237G500 (228) | |
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T M I -'2 j REACTOR C O O L.A N T _
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INVENTORY BALANCE TESTING PREPARED FOR GPU NUCLEAR CORP.
BY 'l EDWIN H. STIER 1
' j l
l INVESTIGATIVE STAFF; l
FREDERICK P. DE VESA ROBERT.T. WINTER q SEPTEMB'BR 5, 1985 VOLUME II (A)
CURRENT GPU SYSTEM EMPLOYEES:
ASSESSMENTS OF INVOLVEMENT IN LEAK RATE TESTING i
= _ __
l INDIVIDUAL ASSESSMENTS: INTRODUCTORY NOTES l
l GPUN requested that we provide information to assist the j 1
l Company in evaluating the conduct of present employees who had I any involveraent in, or responsibility for, leak rate testing et i 1
TMI-2. The selection of individuals to be discussed in this 1 report was left entirely to our discretion.
1 I
i Our assessments of individual behavior are contained in .
1 Volume II comprising 24 sections. Each discusses an individual {
I presently employed in the GPU System. These sections ate arranged alphabetically and include notes citing the supporting evidence contained in Volumes III through VI.
l Volume II is not intended as a self-contained discussion of TMI-2 leak rate testing. It has been written on the assumption that the reader will first become familiar with the 0 Introduction and Overview" in Volume I. That portion of the report discusses general patterns of behavior and key events during the year of TMI-2 operation.
We selected employees to be included in Volume II on the basis of two criteria. First, anyone was included who held a position at TMI-2 during the year of its operation that
involved a responsibility for the. performance or immediate supervision of leak rate tests. This, of course, covered all i l' Control Room Operators ' (CRO's) , but did not include Auxiliary Operators whose duties did not involve them in leak rate l l
testing. Shift Foremen and Shift Supervisors were included I because of the role of Shift Foremen in approving leak rate i
test results and ' the responsibility of Shift Supervisors to i 1
evaluate leakage.
1 i
The second criterion for reporting on TMI-2 personnel is broader in scope. We selected employees who received- 1 I
I information that could have alerted them to the existence of improper leak rate test practices. We paid particularly close 1 attention to information that was available to management.
Such information included the distribution of Daily plant Status Reports, and Shift Supervisors' turnover notes. We also considered evidence of participation in discussions concerning l
1 the rounding off of test results and in drafting the LER in j October 1978. 1 j
Although exposure to such information would not necessarily have been sufficient to make an employee fully conscious of the i
procedural violations that occurred during leak rate testing, j j
it could have been enough to arouse his suspicion. We therefore j l
1 1 1 a
felt that it was important to discuss how such employees responded to any indication that procedures were being violated.
l i
We did not include employees purely on the basis of j 1
speculation. For example, members of the Plant Operations Review Committee (PORC) who simply' ' received the LER but were not involved in its drafting, are not individually discussed.
On the face of the LER, there was nothing that would have- I provided notice of' the underlying leak rate testing problems i
that had led to its issuance. Since no evidence uncovered in our investigation, or to our knowledge in any other l
investigation, raises an implication that management above - the level of the Met'-Ed Vice President for ' Generation received j notice of the problems being experienced in leak rate ' testing, we have not included any such employee in Volume II.
1 The objective of the individual reports contained in Volume II is to provide the Company with the evidence we found concerning individual participation in, or conscious toleration of, improper leak rate test practices. We have not discussed whether anyone who was unaware of such leak rate test practices nevertheless should ' have learned of them. Such an analysis would require a complete understanding of the full range of responsibilities performed by such an individual. We did not-l attempt to investigate the operation of TMI-2 or 'he t
performance of individuals that broadly.
Each section of Volume II contains our conclusions on ;
factual issues. For example, we have attempted in the case of .l; l
each CRO to evaluate any evidence that he may have . engaged 'in test manipulation. However, we have not attempted to reach broader conclusions about the job performance of those whom.we investigated. We also have not expressed opinions- on the-candor and cooperation of witnesses during our investigation, j 1
On those issues, we feel that the record should speak for itself.
l I
l Table-2, located in Volume III (A), has been provided to j I
assist in understanding the results of our technical analysis of all the leak rate tests-performed by each CRO, or approved by each Shift Foreman. That Table contains a series of entries for each shift where a leak rate test was required that was worked by any current employee who was at the time either a CRO or a Shift Foreman at TMI-2. The Table lists chronologically each shift to wnie" the individual was assigned and' sets forth certain data concerning any leak rate tests that were performed on that shift' for which documentation currently exists. The introductory notes at the beginning of Table-2 explain the meaning of the data entries.
4-
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Each discussion in Volume II, along with its supporting evidence, focuses on the behavior of the individual rather than on the group as a whole. Therefore, to some extent, there may l J l-l be differences between our descriptions of individual conduct 4 I patterns of behavior
- and the discussion of the general l
{
i contained in Volume I. This should not be considered to be an i internal conflict in our findings, but rather 'a recognition that each employee should be judged individually.
i INDIVIDUALS INCLUDED IN VOLUME II l ADAMS, Charles BEZILLA, Mark COLEMAN, Mark CONAWAY, William CONGDON, Joseph R.
FAUST, Craig i
FELS, William FREDERICK, Edward )
GARRISON, Jack GUTHRIE, Carl HERBEEN, John l l
BOYT, Kenneth j J
ILLJES, Theodore l KUNDER, George ;
MARSHALL, Walter J.
MCGOVERN, Hugh MEHLER, Brian MILLER, Adam MILLER, Gary P.
POTTS, William ROSS, Michael J.
SMITH, Bernard TROFFER, George ZEWE, William I
l-L CHARLES ADAMS began ' employment with Metropolitan Edison Company- on October- 6, 1975. He is presently . employed _ as an.
Engineering Assistant at TMI-2. Between March 1978 and. March 1979, he worked - as a Shi f t ' Foreman ascigned to TMI-2. He was responsible for supervising- Control Room Operators, ' Joseph-Congdon and Martin Cooper. For most of this period of time, Brian Mehler was his Shift Supervisor.
Analysis of employee testimony, leak rate test records, and related plant documents reveals that Adams failed to properly j supervise the performance of leak rate tests and.also failed to ensure that required action was taken in . response to indications of reactor coolant system leakage' (RCS) during October 1978, January and March 1979. There- is alco l substantial evidence to support a conclusion that' Adams.
participated in, or knowingly tolerated, manipulation 1 of leak rate tests.
Supervision of Leak Rate Testing There is substantial evidence that Adams ;faile6 to properly _
oupervise performance of leak rate tests that were conducted on
l CHARLES ADAMS his shift. He tolerated and participated in the practice of discarding and failing to document all unsatisfactory test results obtained on his shift. He also approved the filing of j numerous test results showing unidentified leakage under 1.0 gpm when they were clearly invalid and did net accurately measure RCS leakage. 3 These conclusions are supported by an analysis of company I
records, as well as the testimony of Adams.
]
I Adams acknowledged that in 1970 the leak rate test was the primary means for determining whether leakage was within the limits set by the Technical Specifications.1 However, he admitted that he viewed the tests as inaccurate and unreliable for this purpose. Adams stated that, as a general rule, leak !
rate test results were viewed as being inconsistent with actual plant leakage and were utilized more for monitoring leakage trends than for measuring leakage at any given point in time.
Despite his attitude about leak rate tests, Adams conceded that he did not recall taking any stepu to improve the accuracy of the leak rate test results. However, he stated that it was possible that he complained to his Shift Supervisor about operation of the plant without knowledge of actual plant 2-
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CHARLES-ADAMS.
leakage.4 Aside from- his possible complaints, Adams did little to ensure that leak rate testing was properly performed on his shift.
It is clear from the testimony and examination of plant records that Adams participated in and condoned the systematic discarding of leak rate test results which indicated that !
unidentified leakage was above 1.0 gpm on his shift. Record s ;
i reveal that-Adams worked a total of 119 shifts f rom March 1978 l
to March 1979.5 Despite his testimony that it was company ;
practice to attempt to perform a leak rate test on each shift, file.d leak rate test results were discovered for only 56 shifts .
that Adams reported for duty.6 None of these filed test results revealed unidentified leakage in excess of 1.0 gpm.
I When confronted with this fact, Adams ultimately admitted that-he tolerated, and participated in, the practice of discarding all leak rate test results demonstrating unidentified leakage to be in excess of 1.0 gpm. According to Adams, all unsatisfactory test results obtained within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> . f rom the l
.last satisfactory test were discarded as a matter of ]
practice. It was his belief that his Shif t - Supervisor, as well as the Supervisor of Operations, knew of thi's prectice.8 l
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CHARLES ADAMS Whan questioned about this practice, Adams at first insisted that after obtaining a leak rate result in excess of 1.0 gpm, he tried to verify the results by looking for leakage l
and checking other plant partneters. He would also document the performance of another leak rate test. If leakage ' was identified, it would be accounted for in the result of the next leak rate test.1 Adams maintained that he kept all unsatisfactory test results in his desk until a sati s f acto ry k
result was obtained. He cculd not explain what happened to those unsatisfactory test results on shifts when it was not possible to obtain a satisfactory result.11 He stated that 1
he discarded only test results that he felt were not j accurate.'2 .
I 1
Adams could not explain what criteria he used in reviewing the test data te determine that a test result above 1.0 gpm was inaccurate.1 He acknowledged that the plant was so unstable between October 1978 and March 1979 that there was no way to determine the accuracy of test results -indicating unidentified leakage to be above 1.0 gpm.14 He admitted that during this period, it became increasingly more difficult to obtain satisfactory test results.15 i ,
l CHARLES ADAMS l
According to Adams, up to four tests might have been performed on his shift before a satisfactory result could be obtained.16 Nevertheless, Adams continued to maintain that he evaluated all unsatisfactory test results and continued to search .for leaks before test results would be discarded.1 This testinony is in direct conflict with that of Joseph Congdon, a Control Room Operator, working under Adams supervision.
Only after lengthy questioning did Adams concede that, given the uncertainty of the verification process, unsatisfactory test results were probably discarded on his !
shift without knowledge of their accuracy.19 i
l Finally, Adams admitted that even when other plant instruments indicated that unidentified leakage was possibly above 1.0 gpm, unsatisfactory test results would still be discarded because it was the practice to discard all test results showing leakage above 1.0 gpm.20 In addition to participating in the discarding of unsatisfactory test results, Adams admitted knowing that no Exception and Deficiency reports were filed and that no log entries were made documenting the unsatisfactory test results l
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!'r-i CHARLES ADAMS that were di scarded . 21 He stated that he knew that the-company procedure requiring Exception and Deficiency reports applied to leak rate tests, but he had no explanation for hi's failure to ensure compliance with the procedure.
Examination of' leak rate test data supports the conclusion that Adams participated in, and condoned, the ' discarding of leak rate test results on his shift. Less than half the shifts worked by Adams have reported - leak rate test results. Two periods where this fact is most prevalent are January and March. j 1979. :
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It is clear from the testimony and other evidence that Adams also participated in, and condoned, the systematic filing of inaccurate leak rate test results while he was employed as a Shift Foreman at TMI-2.
Our review of plant records reveals that over one-third of the tests approved by Adams were inaccurate on their face, were performed with the inaccurate level transmitter- supplying information to the computer, or were otherwise performed in violation of company procedures.24
CHARLES ADAMS As indicated previously, Adams testified that, as a genera]
rule, he considered leak rate test results to be inaccurate and an unreliable indication of actual plant leakage. Despite his perceptions, he first insisted that he reviewed all . leak rate test results showing leakage below 1.0 gpm before 6
approving them. When pressed on the nature of his review, he stated he was not sure what criteria he used.27 After some further thought, he stated that the only purpose of ' the review was to determine that tests showing leakage below 1.0 gpm were not filed when actual leakage was above 1.0 gpm.
However, when asked again what he would do to evaluate the satisfactory results, he stated that he performed only a
" subconscious comparison" with other plant parameters. He also indicated that he assumed that tests showing leakage less than 1.0 gpm were more accurate than unsatisfactory tests.30 Adams admitted that he felt that the plant was so unstable during the last four months of operation that nearly. all the leak rate test results obtained were inaccurate.31 Adams testified that he did not believe that examination of other plant instrumentation could provide sufficient information to determine the validity of the tests that he approved during this period.32 In spite of his perceptions of the test's l
1 CHARLES ADAMS
-inaccuracy, Adams continued to approve and file test results which were below 1.0 gpm because it was administratively 3
required.
Adams also admitted that as a Shift Foreman he did not take j steps to improve the accuracy of the test.34 An examination of the tests that he approved corroborates his testimony.
i Our review of plant records reveals that faulty makeup tank level instrumentation was used during nine of the leak rate l tests approved by Adams. This occurred seven times between December 5, 1978, and January 6, 1979. However, an examination of test data also revealed that on five occasions during the same period, the accurate level transmitter was selected for j the performance of leak rate tests on shifts supervised by ,
Adams.36 When conf ronted with this information, Adams admitted that he was aware that there was a problem with the makeup tank level transmitter in 1978. He testified that the problem' was generally. known in the Operations Department at that time.37 He also understood that large fluctuations in makeup tank level could lead to negative leak rate test results. When shown tests where it was apparent that operators under his I'
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l CHARLES ADAMS supervision intentionally used the accurate level transmitter l for the performance of leak rate tests, he acknowledged that this was apparently done.39 However, he did not recall instructing them to do 'so.40 Because of his admitted knowledge of the instrumentation )
problems, Adams was questioned about the reasons for approving .
the tests of December 30 and 31, 1978, which were performed with the inaccurate level transmitter.41 These tests were of particular concern since test data indicate that Adams approved at least four previous leak rate tests for which the accurate transmitter had been intentionally selected.
1 The test of December 30 was started by another shift, but I
was completed by Adams' shift and approved by him. The test I I
result demonstrated that unidentified leakage was -3.8 43 If Adams shift did not file a satisfactory result, 72 gpm.
hours would have elapsed since the last satisfactory leak rate test result. It is clear from the test printout that there Was a large increase in indicated makeup tank level and pressurizer )
level during the course of the test. In addition,- this was a ,
period when other plant instrumentation revealed that unidentified leakage _ was on the increase and was approaching ;
1.0 gpm. I 1
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CHARLES ADAMS l
When asked why he approved such a test result, Adams admitted that he was probably aware of the transmitter problem at the time, but most likely did not notice which transmitter was on the chart at the time of the test. He conceded that he should have noticed the increase in indicated makeup tank level and pressurizer level on the test' printout and that this type of rise would not normally happen during the course of a leak rate test.45 Further, Adams stated that he thought that the large negative result would have caused him to look at the ' makeup tank strip chart and compare it with the test data. He admits i
that such an observation would readily depict an unsteady condition probably resulting from the faulty transmitter.46 1
When asked if he approved the large negative result because of the approaching 72-hour deadline, Adams stated that he was not certain why he approved the test. He conceded that the result could not have been viewed as accurate. However, after it was pointed out to him that other plant instruments were indicating unidentified leakage above 1.0 gpm, he acknowledged the possibility that he in fact approved the test I
because the 72-hour deadline was approaching.48 CHARLES ADAMS Adame denied he was aware that performing leak rate tests with the inaccurate transmitter would provide a better chance of obtaining a satisfactory result during periods of high
. unidentified leakage.49 l
Adams was shown the test data for the test approved by him on December 31, 1978. The test result demonstrated 50 unidentified leakage to be -2.4 gpm. There were also indicated rises in both the makeup tank level and the pressurizer level for this test. Analysis of the makeup tank level strip chart suggests that the inaccurate level transmitter was shifted to the computer by Adams' shift approximately one and one half hours before the test. When asked why he approved the result of the test, Adams stated that he did so because the result was less than 1.0 gpm and, based on his view of the strip chart, the plant probably was not 1
having substantial leakage problems.
Manipulation of Test Results There is testimony, as well as strong circumstantial evidence, to support the conclusion that Adams tolerated, and participated in, the intentional manipulation of leak rate tests.
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CHARLES ADAMS The NRC alleged that hydrogen was added during six leak rate tests that were performed under Adams' supervision.
Our own analysis confirmed some of these additions and revealed at least one other occasion when hydrogen was added during a test on Adams' shift.53 There is testimony by Joseph Congdon directly implicating Adams in the intentional manipulation of leak rate tests by the addition of hydrogen.
Congdon testified that on February 15, 1979, he participated in the performance of a leak rate test in order to experiment with the effeet of a hydrogen addition on makeup tank level indication. He believes Adams participated with him in this experiment and that the notation on the makeup tank level strip chart which states " pressurized MUT" was made by Adams. Further, Congdon stated that after the experiment he added hydrogen on a number of occasions to manipulate the tests and that both Martin Cooper, a Control Room Operator on his shift, and Adams, were aware of this fact. 4 In support of his belief, Congdon testified that he thinks he had conversations with Adams about the addition of hydrogen during leak rate tests in order to manipulate the test results. He further stated that when he manipulated test I
i
CHARLES ADAMS results, he did not make any ef fort to conceal his activities and that members of his shift worked very closely with each other.55 l
l l It should be noted that William Conaway, a Shift Foreman on l
l Gnother shift, testified that he recalled a conversation with l
l Martin Cooper, after the accident, where he got the impression
! that Cooper was aware of hydrogen's effect on leak rate test results during the 1978-1979 time period. 6 Brian Mehler, Adams' Shift Supervisor. testified that he had been aware of hydrogen's effect on makeup tank level since 1977, when he was working at TMI-1.57 Despite this knowledge on the part of his colleagues, Adams testified that he did not recall being aware of hydrogen's effect on leak rate test results during the 1978-1979 time period. Nor does he recall knowing at that time that hydrogen additions had an effect on makeup tank level indication.58 According to Adams, he had no recollection of any discussion with Operations personnel about the possible effect of hydrogen on makeup tank level. However, when confronted 1 with Congdon's statement regarding his knowledge of test i manipulation, Adams did not categorically state that it was !
untrue. On the contrary, he acknowledged the possibility i:. hat
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CHARLES ADAMS
{
Congdon was telling the truth.60 When specifically confronted with Congdon's statement that Adams knew that he was adding hydrogen during the course of leak rate tests in order to manipulate the results, Adams acknowledged that, although he did not recall, it was possible that he was aware of such conduct.61 1
Adams was asked to review the data for specific tests in which MPR confirmed. additions of hydrogen. The first test was performed by Cooper on February 15, 1979, and approved by l
Adams. This test was identified by Congdon as the one in which j the experiment was conducted.62 After reviewing the documentation, Adams conceded that the indicated rise in the makeup tank level during the test was caused by the hydrogen addition.63 When asked to look at the notation on the chart which stated " pressurized MUT," Adams could not conclusively say that it was not his handwriting. In fact, he testified that it was possible that it was his handwriting.64 F er, I although he did not recall participating in the experiment, he stated that it was quite possible that he did. Adams further stated that based on the way that he ran his shift, it was likely his subordinates would have told him they were conducting the experiment.66 1
CHARLES ADAMS Adams was also asked to review documents relating to a test that was performed by Cooper and Congdon on February 19 and approved by him.67 This test was the next test filed on Adams' shift after the February 15 test, and it also apparently involved a hydrogen addition during the course of the test.
l After a review of . the strip chart, Adams admitted that there j was a rise in the makeup tank level trace similar to the one ]
which occurred on February 15.68 When asked to review the data for the test of March 1, 1979, which he also approved, he also recognized a rise in level which we have attributed to a logged hydrogen addition just before the end of the test.
1 Nevertheless, Adams continued to maintain throughout the deposition that he was not aware of the effect of hydrogen on-O leak rate tests in 1979. He repeatedly stated that if he i knew his operators were adding hydrogen to manipulate leak rate test results, he would not have approved the tests and would have instructed his operators not to add hydrogen during the 1
course of a test. However, he had no recollection of ever giving these instructions.
When pressed further on what he would do were he aware that his operators were manipulating leak rate tests, . Adams stated that he would have taken no disciplinary action other than to advise his supervisor. 3 l
CHARLES ADAMS-Although Adams initially made the. general statement that he would not cpprove tests that were manipulated by the addition-of hydrogen, he later qualified his statement. Adams acknowledged that even if he knew operators were attempting to manipulate tests by. adding hydrogen, he would approve.the test result if he thought the hydrogen made the level more accurate, or if, in his mind, the addition did not affect the test results.74 There is no conclusive evidence that Adams participated in or condoned the manipulation of leak rate tests by j unaccottnt ed-for or accounted-for water additions during the course of the test.
The NRC alleged that unaccounted-for water additions were made during 18 of the tests approved by Adams. MPR was not able to confirm any of these additions. Four of the 18 allegations were based on incorrect chart time analysis.
Four of the allegations are based on analysis of strip chart data that were inaccurate. During these tests. the faulty makeup tank level transmitter was supplying data to the strip chart recording instrument, and conclusive identification of water additions from the strip charts is impossible. In CHARLES ADAMS the remaining tests, we were unable to confirm a perceptible j change in makeup tank trend clearly attributable to a water addition.
For the most part, when Adams was confronted with the data for these tests, he was not able to identify any obvious water additions. Further, he stated he would not npprove a test i
result if he knew water were added and not accounted for in the i test calculation. He denied having knowledge that some operators were manipulating tests by " jogging" small amounts of water into the makeup tank during the test.80 )
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Lastly, Adams stated he was not aware that operators were J manipulating test results by making water additions and accounting for them in the test calculation, and thereby taking advantage of known instrument errors.81 Plant records tend to support his testimony. Only one test result approved by Adams falls into this category. That test was actually performed by the previous shift.82 Moreover, the test v:as performed on March 24, 1979, during a period when water additions were being made quite frequently and easily could have overlapped with the running of a leak rate test.
1 CHARLES ADAMS 1
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Operator Response to Indication of Excessive Leakage 1 Adams recognized that, as a Shift Foreman at TMI-2 in 1978-79, he was responsible for monitoring and evaluating RCS leakage. He also understood that it was his responsibility to i
ensure that limiting conditions for operation for RCS leakage were not exceeded.83 According to Adams, if the limiting
)
conditions for operation were exceeded, it would be necessary to reduce leakage to within the limits, or shut down the plant ]
l within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. Although he knew that he had the authority to do this, he stated that he would not normally do so without approval of a Shift Supervisor.84 Adams testified that the leak rate test was the method used to determine compliance with the limiting condition for operation.85 However, he stated that the leak rate. test was inaccurate and unreliable for this purpose, and that other plant instrumentation also had to be relied upon.86 After lengthy questioning, Adams stated that during the last four months of the plant's operation, the plant was so unstable that I neither the leak rate test nor the other plant instrumentation could be relied upc:i to determine with certainty that the plant was operating within the 1.0 gpm limiting condition for operation.
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l CHARLES ADAMS Adams stated that despite the inaccuracy of the leak rate test and other plant instrumentation, he made some effort to evaluate test results and approximate leakage for purposes of compliance with the Technical Specifications. Moreover, he did not believe he intentionally operated the plant in violation of the Technical Specifications.89 Despite these statements, our investigation revealed at least three periods when there were indications that unidentified leakage may have exceeded 1.0 gpm, and it does not {
appear that Adams made efforts to ensure that the required action was taken in response to the leakage.
1 October 16 < 22, 1978 On October 15, 1978, Operations personnel began to I
experience difficulty obtaining ' satisfactory leak rate test '
results. On October 16, an unsigned test result was )
obtained showing unidentified leakage at 2.56 gpm.91 On .
1 October 17, plant records reveal that operators were searching for leakage.92 However, there is no indication that efforts were undertaken to chut down the plant. On the day shift of October 17, Coleman performed a leak rate test showing unidentified leakage at 2.07 gpm. Plant records reveal that there were continuing attempts to identify the l
CHARLES ADAMS I leakage.94 On the 11pm-7am shift on October 18, an unsigned leak rate test was performed showing unidentified leakage to bc 1 1.77 gpm.95 Ken Bryan, the Shift Supervisor for the lipm-7am shift, wrote in his turnover notes, "Still cannot get a leak rate - 1900 today is deadline Doing hand calculations. Can not find leak -
don't believe it's in the RB [ reactor i
)
buildi ng ] . " 96 Still, there is nothing in plant records to !
indicate they were proceeding to shut down the plant at this 1
1 time, j Adams' shift reported for duty on October 18 (the day shift). They were not working on October 16 and October 17.9 Adams testified that as a Shift Foreman he 1
probably would have reviewed documentation generated by the I previous shift pertaining to plant leakage, including Bryan's turnover note. Four leak rate tests were performed on l
9 Adams' shift. The test performed at 07:36 was unsigned l with a result indicating unidentified leakage to be 1.29 gpm. l It contains the handwritten note "ok by round off. JRF 1200."
The second test was performed at 08:59 with a result of 1.32 gpm. It too contains a written note stating "ok by round off -
JRF." The third test was performed at 10:18, signed by Adams I and approved by Mehler. The result is 1.02 gpm. Mehler writes
" Net unidentified leak rate rounded off to nears [ sic] whole 1
l
CHARLES ADAMS number 1.0 gpm." The last test is at 12:21 with the result of .
-0.2 gpm. It was signed by Olson and approved by Adams.
Adams had no specific recollection of these tests, but >
believes that the handwriting pertaining to the round off in the test conducted at 07:36 and 08:59 is that of James Floyd.1 He stated he had a vague recollection of the events of October 18. He did recall that Floyd was present in
- the control room, possibly performing leak rate tests.1 .-
Although he had no specific recollection of the tests, he believed, given his practice as Shift Foreman, that he probably reviewed them, even though they were unsigned.1 He said he had no recollection of the round off practice despite the fact that he signed the first test which was filed using this method.1 .
Although Adams first contended that the plant was in the action statement on his shift, he later conceded that this belief was based on his present review of the leak rate test data of October 18 which states that this was the case. He admitted he did not recall entering the action statement at that time and that there is no indication from his review of the logs that he had done so.104 l
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I CHARLES ADAMS l 1 Adams had no recollection of doing anything on his shift to .
reduce leakage; nor ' could . he recall any. discussion about the round of f policy being the basis for reducing RCS leakage and getting out of the action statement. Adams admitted that-if the leak rate test result's were considered valid, steps should have been taken to enter the action statement.106 Although he had no specific recollection of the LER that was writ. ten pertaining to the events of October 18, he believes he probably read it.107 After reading both the LER and Floyd's Operations Memo, dated October 20, Adams conceded he i i
should have interpreted them to mean that any time a leak rate I test indicated unidentified leakage above 1.0 gpm, the action statement should be implemented. He acknowledged thht neither the LER nor the Operations memo changed his practice of failing l to do so. 108 In any event, Adams could tot explain why he did not cause the required action to be taken during this period.
December 26, 1978 - January 15, 1979 Plant records reveal that Adams worked for almost t'his entire period.109 Our analysis indicates that unidentified leakage exceeded 1.0 gpm for most of this period.
1 CHARLES ADAMS After reviewing plant records, Adams stated he had only .. a vague recollection of a leakage problem that existed during this time.110 Adams conceded that given all the indications of p1'nt a
leakage during this time, it was likely he would have performed leak rate tests in order to help evaluate the problem.'111
! After lengthy questioning where it was pointed out to him that l
l he had worked many shif ts during the period ' without filing test resultu.s Adams conceded that his shift probably obtained' unsatisfactory tests during this time. Adams also admitted that despite the indications of high unidentified leakage, those test results above 1.0 gpm were most likely discarded simply because they were above 1.0 gpm and were within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> since the last successful test result.11 He had no explanation for why they were discarded and for why the required action was not taken. I Based on his own testimony and that of others, it is highly likely thet numerous satisfactory test results were obtained on i Adams' shift during this peri od which werc discarded and the requitad action not taken. Test data supports this conclusion. Out of the 16 shifts worked by Adams during this 1 1
period., only four have filed test results.114 l
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i CHARLES ADAMS l l l I
March 15 - 29, 1979 Our analysis indicates that, during this period, l unidentified leakage increased until it came close to 1.0 gpm I
on March 16, 1979, and stayed fairly constant thereafter.
However, for the reasons discussed in Volume I, operators would have percef.ved unidentified leakage to be much greater. Adams' chift was working every day from March 21 through March 25.115 During this period, only one leak rate test was )
I filed by his shift.116 This test was altually performed by l
the previous shift and approved by Adams when he came on duty <
l Adams testified that he recalled a change in the leak rate test procedure where the level for the reactor coolant drain tank was manually computed by the operator to correct an error in the computer calculation. 17 As a result of the manual correction of the calculation error, test results in61cating unidentified leakage should have been perceived to be more accurate and reliable. Nevertheless, Adams stated that the practice of discarding leak rate test results continued during this period. Asnuming Adams' actions yere consistent with his previous testimony about the practice of discarding test results in excess of 1.0 gpm, it is likely that all such tests obtained during this period were discarded without taking the required action.
CHARLES ADAMS 1 Adams 3/8/85, pp. 75-76, 99, 169, 2 Ibid., pp. 14-15, 61, 68, 95, 98, 102.
3 Ibid., p. 70.
4 Ibid., p. 130.
5 Vol. III, Table 2.
6 Ibid.
7 Adams 3/8/85, pp. 92-93, 129; /-
3/19/85, p. 13.
8 Adams 3/8/85, p. 131.
9' Ibid., pp. 8, 108-109, 10 Ibid., p. 30.
11 Ibid., pp. 21, 78, 82.
12 Ibid., pp. 138-139. l 13 Adams 3/8/85, pp. 77-78; 3/13/85, p. 10.
14 Adams 3/8/85, pp. 14-15, 115-116.
15 Ibid., pp. 59, '? 3 , 74.
1 16 Ibid., p. 81.
17 Adams 3/13/85, p. 5.
18 Congdon 2/13/85, pp. 33-34.
19 Adams 3/8/85, p. 22-23, 118-119.
20 Adams 3/19/85, p. 13, 21 Adams 3/8/85, pp. 118-121.
22 Ibid., pp. 121-122.
I 23 Vol. III, Table 2.
[ corrected 1/17/86]
_ _ _ _ _ _ _ _ _ _ _ _ _ _ 1
CHARLES ADAMS l
24 Vol. III, Table 2.
25 Adams 3/8/85, pp. 14-15.
26 Adams 3/8/85, p. 19; )
3/13/85, pp. 11-12.
27 Adams 3/8/85, pp. 77-78; 3/13/85, p. 10.
28 Adams 3/13/85, p. 16.
29 Adams 3/8/85, p. 108.
30 Ibid., p. 132. a i
31 Ibid., pp. 64-65, 68. j 32 Ibid., pp. 118-119.
33 Ibid., pp. 75-76. j l
34 Ibid., pp. 70-71.
35 Vol. IV (MPR Report), Appendix K, Test Numbers 121, 110, 107, 105, 99, 79, 78, 76, 72.
36 Vol. IV (MPR Report), Appendix K, Test Numbers 109, l 103, 96, 79, 69.
37 Adams 3/8/85, pp. 47-48; l 3/13/85, pp. 120, 140-141.
38 Ibid., pp. 125-126.
39 Ibid., p. 125.
40 Ibid., p. 126.
41 Vol. IV (MPR Report), Appendix K, Test Numbers 78, 76.
42 Ibid., Test Numbers 109, 103, 96, 79.
43 Ibid., Test Number 78.
44 Adams 3/13/85, p. 131.
45 Ibid,., p. 131.
[ corrected 1/17/86]
.(:
N ,
CHARLES ADAMS X. ]
1\x Adams 3/8/85, pp. [7 5- 76, 99, 169. -
.N 2 \ Ibid. , pp. 14-15, til , 68, 95, 98, 102. j L3
\
- l. -- Tbid., p. 70.
4 Ib ., p. 13'O.
5 Vol. I, Table 2.
6 Ibid.
7 1
. Adams 3/8/ , pp. 92-93, 129; 1 3/19/ , p. 13. I 8 Adams 3/8/85, . 131.
9 Ibid., pp. 8, 10 109.
10 Ibid., p. 30.
11 Ibid., pp. 21, 78, 82, 1
12 Ibid., pp. 108-109.
13 Adams 3/8/85, pp. 77-78; 3/13/85, p. 10.
14 Adams 3/8/85, pp. 14-15,-115-1 6.
15 Ibid., pp. 59, 73, 74.
16 Ibid., p. 81.
17 Adams 3/13/85, p. 5.
18 Congdon 2/13/85, pp. 33-34.
19 Adams 3/8/85, p. 22-23, 118-119.
20 Adams 3/19/85, p. 13.
21 Adams 3/8/85, pp. 118-121.
22 Ibid., pp. 121-122.
23 vol',,III, Table 2.
.. . N
\
CHARLES ADAMS
\ l
\s j 24 Vol. IXI, Table 2. ]
i 25 Ns Adame 3/8/85, pp. 14-1$. {
26 \ Ad ams 3/8/85, p.19; l 3/13/85, pp. 11-12. .
27 Ada s 3/8/85, pp. 77-78 l 3/13/85, p. 10, 28 Adams 3 3/85, p. 16. j
'1 29 Adams 3/8 q5, p. 108.
30
)
Ibid., p. 132 1 31 Ibid _., pp. 64 , 68.
1 32 Ibid., pp. 118-11 . l l
33 Ibid., pp. 75-76. j 34 Ibid., pp. 70-71.
1 35 Vol. IV (MPR Report), pendix K, Test Numbers 121, 110, 107, 105, 99, 79, 78, 76, 72.
36 Vol. IV (MPR Report), Appe dix R, Test Nurbers 103, !
103, 96, 79, 69. l 37 Adams 3/8/85, pp. 47-48; 3/13/85, pp. 120, 140-141.
38 Ibid., pp. 125-126. N N
39 Ibid., p. 125. '\
40 Ibid., p. 126, 41 Vol. IV (MPR Report), Appendix K, Test Numbe,s 78, 76.
42 Ibid., Test Numbers 109, 103, 96, 79.
43 Ibid., Test Number 78.
44 Adams 3/13/85, p. 131.
45 Ibid., p. 181.
i-l l
4 CHARLES ADAMS-46' Adams 3/13/85, pp.'134-137..
'47 Ibid., pp. 131-132, 137.
'48 Ibid., pp. 132, 140.
49 I, bid., pp. 137, 139.
50 Vol. IV (MPR Report), Appendix K, . Test Number 76. .
51' Adams 3/13/85, pp. 137-139.
52 voi, Iy (gpR . Report), Appendix K, . Test Numbers 122,
]
119, 115, 78, 38, 24. ;
i 53 Ibid., Test : Number 32.
54 Congdon 2/13/85, pp. 54-55.
55 Ibid., pp. 56-57,.59-62.
56 Conaway 2/21/85, pp. 70-72. N 57 Mehler 3/15/85, p. 2.
58 Ada as 3/13/85, p.120; 3/19/85, pp. 36, 42, 46, 50-51, 58. -1 59 Adams 3/19/85, pp. 36, 41.
60 Ibid.,, p. 42.
l 61 Ibid., p. 43. ,
.i 62 -Vol. IV (MPR Report), Appendix K, Test Number 38; l Congdon 2/13/85, p. 109.
~3 o Adams 3/19/85, p. 33.
64 Ibid., p. 34. 4 65 Ibid., pp. 38, 42.
66 Ibid., p. 40.
67 voi, Iy.(MPR Report),-Appendix-K, Test Number'32.
68 Adams 3/19/85, p. 54.
i
.q CHARLES ADAMS 69- Vol. IV (MPR Report), Appendix K, Test Number 24;'
l 1 Vol III, Table 2; l l
Adams 3/19/85, p. 56.
70 Adams.3/19/85, p. 60. l 1
71 Ibid., pp.-51-53. J
)
72 Ibid., p. 52. !
73 Ibid., pp. 46-47. !
I4- Ibid., pp. 58-60.
]
75 Vol. IV (MPR Peport), Appendix K, Test Number s . 157, j 156, 144, 139, 133, 129, 115, 109, 99, 96, 79, 78, 76, 72, 63, 47, 28, 23.
76 Ibid., Test Numbers 156, 139, 76, 47.
77 Ibid., Test Numbers 115, 109, 96, 79.
78 Adams 3/13/85, pp. 122, 123, 124, 125, 144; 3/19/85, p. 30. ,
1 79 Adams 3/13/GS, p. 70. '
80 Ibid., p. 122. )
l 81 Adams 3/19/85, pp. 63-64.
82 Vol. IV (MPR Report), Appendix K, Test Number 4.
83 Adams 3/8/85, pp. 7, 10.
84 Adams 3/8/85, pp. 39-40, 98, 103, 105-106; 3/13/85, p. 63.
85 Adams 3/8/85, pp. 76-77, 99, 169-170.
86 Ibid., pp. 14-15, 61, 68, 94-96, 98-99.
87 Ibid., pp. 39-40, 61-62, 64-67, 89-91, 99, 103-104, J 113-119.
88 Ibid., pp. 95-96,98-100.
)
CHARLES ADAMS y 89 Adams 3/8/85, pp. 111-112, 135, 138; 3/13/85, pp. 1).-12.
90 Vol III, Table 4.
91 vol. Iy (gpa Report), Appendix K, Test Number 149.
92 Vol. III, Table 4.
93 Vol. IV (MPR Report), Appendin K, Test Number 148..
94 Vol. III, Table 4.
95 Vol. IV (MPR Feport),. Appendix K, Test Number 2.47.
96 TM1-2 Daily Plant Status Report, October 18, 1978 (Tab 10).
97 Vol. III, Tables 1 and 2.
98 Adams 3/13/05, pp. 22, 88.
99 Vo '. . IV (MPR Report), . Appendir K, Test Numbers 146,
! 145, 144, 143.
100 Adams 3/13/85, p. 26.
102 Ibid., pp. 28, 37, 47. i 102 Ibid,,, pp. 33-34.
103 Ibid., pp. 28, 46.
104 Ibid., pp. 35-42, 57.
105 Ibid.., pp. 30-32.
106 Ibid., p. 63.
107 Ibid., pp. 83-84.
108 Ibid., pp. 85, 90,98-100.
109 Vol. III, Table 2.
)
J 110 Adams 3/13/85, pp. 148-149. I 111 Adams 3/19/85, pp. 6-7. ;
i
i 1
l CHARLES ADAMS 1 112 l !
l Adams 3/19/85, p. 13. l
! l 113 Ibid., p. 13. i 114 Vol. III, Table 2.
115 Vol. III, Table 1 and 2.
116 Vol. IV (MPR Report), A'ppendix K, Test Number 4.
l- 117 Adams 3/19/85, p. 61.
l l 118 Ibid., p. 61.
I 1
l
)
l l
1 l
l l
l l
1 I,
[ corrected 1/17/86)
.I 1
1 i
e
'Nx
\s CHARLES ADAMS Ibid., p. 13.
112'\ '
113 Ibid., p. 13.
114 'Vol . III, Table 2.
\ l 115 vol\ III, Table 1 and 2.
N <
\ 0 116 Vol. .t 1 (MPR Report), Appendix K, Test Number 4. j 117 Adams 3 /85, p. 61.
118 Ibid., p. .
I
'1 l
l' i
t
)
l l
i i
l l
1 l
l
____ _ _ J
- - _ _ _ _ _ - _ _ _ - _ _ _ - - = _ _ _ _ - . _. - _ _
l i
MARK BEZILLA began employment with Metropolitan Edison Company in 1976. He is presently employed by GPU Nuclear as a control room operator at TMI-1. In 1978 he was assigned as the
[
i Procedure Coordinator and Plant Operations ' Review Committee (PORC) Secretary at TMI-2. During this time period, James j
' .l Seelinger, Plant Operations Review Committee (PORC) Chairman and Superintendent of Technical Support at TMI-2, was his immediate supervisor.1 i
During the course of our investigation, we found no evidence to suggest that Bezilla was involved in improper leak ,
gate testing practices at TMI-2.
As Procedure Coordinator and PORC Secretary, Bezilla had virtually nothing to do with leak rate testing at TMI-2. He did not personally perform any tests, nor did he exercise direct responsibility for their oversight. Bezilla testified that in 1978-1979 he spent limited time in the control room and that he was not aware that operators were manipulating leak rate test results.2 We found nothing in the company records to refute his statements and there is no testimony that links ,
Bezilla to improper leak rate testing practices at-TMI-2. The only connection that we discovered between Bezilla and Jeak N
s MARK BEZILLA rate testing during our investigation stemmed from his I
)
involvement in the drafting of Licensee Event Report (LER) 78-62.
! Bezilla testified that in October of 1978, he was asked by James Seelinger to assist with the drafting of ' LER 78-62.3 l
Our investigation revealed that this LER conveyed misleading l
information to the NRC regarding the activities of October 16-18, 1978. LER 78-62 dealt with the failure of 'IM I- 2 ,
\
operations Department personnel to take required action in I response to excessive RCS leakage on October 16, 1978. Our investigation revealed that the LER-did not accurately describe the action that was taken in response to the indications of leakage at that time. Specifically, we found that' the LER contained inaccurate information about the cause of the I violation, the time of its discovery, the time Operation; q personnel entered the action statement, and the time and method by which they brought the leakage to within acceptable limits.
The LER also reported remedial action which was not effective in correcting the behavior of plant personnel.
Because our investigation revealed Bezilla's involvement in both the preparation and follow up of LER 78-62, we questioned him extensively on this uuoject.
- _ _ _ - _ .-__ =_____
r 1 i
MARK BEZILLA Bezilla said that Seelinger briefly~ explained to him that licensed personnel had failed to implement the action statement with respect to a limiting condition for cperation because of their- improper interpretation of the Technical l Specifications.4 He further stated that Seelinger
~
essentially advised him that leak rate test results exceeding Technical Specifications had been obtained within a '72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> period from the last satisfactory test result and for that reason, the action statement had not been implemented.5 Bezilla recalled that Seelinger provided him with perhaps three tests which related to the incident.6 Bezilla understood that the purpose of the LER was to ensure that the action statement was implemented whenever leak rate test.results were obtained exceeding the limiting condition for operation, regardless of the elapsed time from the last ' successful test gesult. There was no discussion that he could recall relating to the propriety of discarding leak test results.8 Bezilla testified that after receiving his instructions from Seelinger, he talked to Shift Supervisors, and possibly the Supervisor of Operations, about the incident in an effort to find out more of the details. Bezilla had no recollection of the specifics of his inquiry.9 In an attempt to refresh his recollection, Bezilla was asked to review several documents.
l related to the preparation of the LER.
l
1
~j MARK BEZILLA
)
Bezilla was shown the handwritten draft- of the Prompt Report that Seelinger sent to the NRC on October 19, 1978, q which first reported the incident in ' question. O We asked Bezilla about his role ~in preparing the Prompt Report, and )
l '
a"'
specifically if he had any knowledge of the. circumstances l
l i
surrounding the change in the draft that reported the date of discovery of the event as October 19, instead of October 18,-
when the discovery actually took place. Bezilla acknowledged that his handwriting was.on most of the draft, but. stated that the portion of the draft that changed the discovery date of the 'I 11 event appeared to be in Seelinger's handwriting . Bezilla testified that he could not recall any discussions about the l change in the Prompt Report, nor could he recall why it was' 4
made.12 We also asked Bezilla to review the handwritten draft of the actual LER in an attempt to shed further light on'his role in its preparation. After reviewing the draf t, - Bezilla stated that the bulk of the handwriting appeared to be that of James Stair, a licensing ' engineer who was assigned to work with Bezilla on the preparation of the LER. Bezilla' explained that it was his responsibility to provide the factual information regarding the event to Stair, who was then /
responsible for actually writing the draft.14 Bezilla i
testified that he also thought some of the. handwriting on the-
_ _ _ _ - - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ _ _ .- a
i I
l MARK BEZILLA draft LER was Seelinger's.15 According to Bezilla the
/- practice at the time was for Seelinger, as PORC Chairman, to review the handwritten draf t and make any necessary changes I before submitting it to Met-Ed Licensing in Reading, Pa. O f
.\
.d Bezilla also reviewed the typewritten LER that was '{
ultimately approved by PORC, and which stated that the l
occurrence was discovered on October 19 at 19:00 hours during- l the course of a leak rate test.1 Bezilla acknowledged that this statement did not appear to be accurate. He could not i 1
explain why this statement was in the report other than to l
l speculate that PORC decided on the language and he was told that this was the wording to be used.18 l
l Next Bezilla was shown the final typewritten copy of the l
LER that was sent by Herbein to the NRC. We specifically asked him about the language in the LER narrative which states that unidentified leakage was reduced to within allowable limits by determining a portion to be identified leakage. The language was not in the original LER approved by PORC. Bezilla stated that he had no recollection of any additions being made to the LER after it was submitted by PORC to Reading.19 He testified that, based on the practice at that time, <
comeone in Reading who had a question or wanted to make a 5.-
~
l MARK BEZILLA
, change would have verbally contacted Seelinger with the
! i
! request.20 Bezilla had no recollection of any discussions f about the change or why it was made.21 Finally, we questioned Bezilla about the letter written by Seelinger to the NRC dated August 9, 1984, in which Seelinger stated that he promptly informed 'IMI-2 Operation's personnel of the requirements set forth in the LER. Bezilla stated he did not attend any meetings concerning the LER. However, he recalled hearing from other engineering personnel that Seelinger had held meetinga on the LER's contents.
1 I
Since Bezilla testified that one of his responsibilities as I PORC St cretary was to iollow up on PORC action items, he was questioned specifically about what he did to follow up on the action item pertaining to LER 78-62.24 Item III of the first paragraph of the PORC action item states as follows:
WJM-Insure the following is documented by Ops review of LER 78-62/IP(IT): " The appropriate personnel will be instructed on the requirements of the applicable sections for the T.S. and the reqv.irement to immediately invoke applicable action statements when the provisionc of the LCO's are not met."25 t
.a <S V
\/
l #
3
~ . . --
MARK BEZILIA In explaining the meaning of the action item, Bezilla q l
testified that company practice at the time would have simply j l
required that Walter Marshall insure that Operations personnel {
signed the document review form attached to the LER.
l 1
Plant records reveal that this task was not completed by l
Marshall until March 5, 1979, three months after the last l l
extension date requested by Bezilla.27 l j J
Bezilla contended that both the sign-off requirement and '
the extension requests were considered to be mere formalities and speculated that plant personnel were probably advised before that date of their responsibilities to take appropriate action in response to excessive leakage.28 Bezilla stated, "The PORC action items were more of just a tool we used to make it easier to recover information and data for people who later on might want to look at that item." 9 With respect to his responsibility to follow up on action items, Bezilla stated that once the action item was assigned, the only thing he would do would be to periodically check on the status of the sign off.30 1
]
l i
j MARK BE7JLLA Bezilla was shown a copy of the NRC Inspection Report of Donald Haverkamp dated January 26, 1979, wherein for . the first time the NRC makes mention of LER 78-62. The report i indicates that Bezilla was one of the people contacted during the course of the inspection.
l In that report, the NRC states that it reviewed the follow-up action taken by the Company in regard to LER 78-62, l found that it was satisfactory and closed the item.
l l
I Bezilla had no recollection of being contacted by the NRC with respect to the LER. He did not think it unusual that the LER was not mentioned in previous reports or that the company response was found satisfactory on that date, even though it ]
was still not completed.32 Bezilla stated that he was not aware that Operations-personnel were adding water or hydrogen during the course of leak rate tests in an effort to manipulate the test results.33 Subsequent to the filing of the LER, it was his belief that operators were complying with the requirement of the LER. He was not aware that the practice of discarding tests was occurring.34 i
MARK BEZILLA There is insufficient evidence- to conclude that Bezilla knowingly participated in the submission of the inaccurate LER to upper level management and the NRC. Given his lack of familiarity with the leak rate test procedures and the practices governing its performance, it appears he relied primarily on instructions and information supplied to him by James Seelinger.
t l
l l
l I
l l
MARK BEZILLA 1 Bezilla 2/22/85, p. 9; 2 Bezilla 4/6/84, pp. 8-9, 11-12, 19-20.
3 Bezilla 2/22/85, pp. 10-11.
4 Ibid., pp. 12-13.
5 Ibid., pp. 12, 14.
6 ,
Ibid., p . 12 . .
7 Ibid., pp. 13, 21, 32-33.
8 Bezilla 4/6/84, pp. 13-14; 2/22/85 pp. 32-33.
9 Bezilla 2/22/85, pp. 13, 21-22.
10 Letter, J. Seelinger to B. Grier (NRC), Prompt Report, October 19, 1978, (Tab 31);
Bezilla 2/22/85, p. 15.
11 Bezilla 2/22/85, pp. 16-17.
12 Bezilla 2/22/85, pp. 18-19.
13 Ibid., p. 24.
14 Bezilla 2/22/85, pp. 19-20; 4/17/85, pp. 7-8.
15 Bezilla 2/22/85, p. 24.
16 Bezilla 2/22/85, pp. 26-27.
17 TMI- 2 Licensee Event Report .78-62/1T, November 1978, (Tab 28).
18 Bezilla 4/17/85, pp. 20-21.
19 Ibid., pp. 23-24.
20 Ibid., pp. 23-24.
~21 Ibid., p. 26.
l MARK BEZILLA 22 Bezilla 2/22/85, p. 34; Letter, J. Seelinger to N. palladino, August 9, 1984, l (Tab 36).
l !
l 23 Bezilla 2/22/85, pp. 35-36. l l
24 Ibid., p. 3.
1 25 Document Review Sheet for LER 78-62/1T, (Tab 30). !
l l
26 Bezilla 2/22/85, pp. 36-37.
I i
j 27 Document Review Sheet for LER 78-62/lT, (Tab 30). l 28 Bezilla 2/22/85, p. 38. I 29 Ibid., p. 39.
i 30 Ibid., pp. 28-29.
31 U.S. NRC Inspection Report, January 26, 1979, (Tab 33).
32 Bezilla 2/22/85, pp. 48-49.
33 Bezilla 4/6/84, pp. 11-12, 19-20.
34 Ibid., pp. 11-14.
l 1 l
l l
l MARK COLEMAN began his employment with Metropolitan Edison (MET-ED) in January 1974. In the fall of 1976, he l became a Control Room Operator at TMI-2. Coleman held this position until August 1983 when he assumed his present position as a Training Instructor at TMI-2. Normally, Dennis Olson and Leonard Wright were the other Control Room Operators assigned on shift with Coleman. He was usually supervised by Shift Foreman, Adam Miller, and Shift Supervisor, Gregory Hitz.
i l i Analysis of employee testimony, Reactor Coolant Inventory Balance tests (leak rate tests) and related plant documentation i l
l L
suggests that Coleman failed to properly utilize leak rate tests for the purpose of measuring reactor coolant system (RCS) leakage and also failed to take required action in response to l indications of excessive RCS leakage. '
Coleman also admitted that he knowinoly manipulated leak rate test results by adding hydrogen and water during the I
course of the tests.
i L________ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ _ - - - - _ - - _ - - - - - . . - - - - . - - - -
1 l
I l
l MARK COLEMAN These conclusions are based on the following:
3 Utilization of Leak Rate Tests to Measure Leakage I
There is convincing evidence that Coleman failed to use the leak rate test to measure RCS leakage. Coleman's testimony, as 1
well as examination of plant- records, reveals Coleman's j l
attitude that the leak rate test results were meaningless as a method of determining actual plant leakage.1 He had litt.'.e confidence in the results and considered the test an
' administrative burden that had to be completed every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />.
His attitude toward leak rate testing is quite clear from the manner in which he conducted the testing. To begin with, ;
j he discarded all leak rate test results showing unidentified 1
leakage above 1.0 gpm occurring within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> of the last I satisfactory result.3 In addition, there was a practice on Coleman's shift to file satisfactory tests even if they were inaccurate on their face, performed with fault? instrumentation or violated test procedures.4 Furthermore, Coleman filed test results which were inaccurate as a result of his
-l intentional manipulation.5
MARK COLEMAN Discarding Test Results l Coleman considered it his duty to try to obtcin a
! satisfactory test result on each shift that he worked.6 l
However, he admitted discarding all tests above 1.0 gpm that j l
were obtained within 72 hours of the last satisfactory l l
l result.7 Coleman explained that he learned of the practice of d'iscarding all tests above 1.0 gpm early on in his l 3
employment as a Control Room Operator. He recalled a f
I conversation with a Shift Supervisor which led him to believe l that was the practice to be followed.8 Coleman did not recall who the Shift Supervisor was although he said his first I Shift Supervisor was Michael Ross, who was later replaced by Gregory Hitz.9 Coleman further testified that sometimes a number of tests would be discarded on the same shitt.40 Coleman recalled one ;
occasion where he was instructed by his superiors to run as many tests as necessary until he obtained "a good one."11 Test data from Coleman's shift is consistent with his testimony. An examination of leak rate test data revealed that, prior to February 25, 1979, Coleman worked on 98 shifts when leak rate tests coind presumably have been performed.12
- a
I i
i I
MARK COLEMAN -
For 59 of those shifts there were no leak rate test results 1 j
filed.13 After February 25, 1979, there was a leak rate test filed for every shift that he worked.14 It should be noted i
l that nearly all of these tests were manipulated by making water l
}
l additions near the end of the test that assured lower values 1 for indicated unidentified leakage.15 ;
i i
The testimony and analysis of plant documentation clearly 1 indicate that numerous test results above 1.0 gpm unidentified '
leakage were systematically discarded while Coleman was on ;
duty; and that the only extended period of time where this j practice appears to have diminished is when tests were l intentionally manipulated by adding water during the course of 1 i
1 the test, i 1
Filino Inaccurate Test Results .
j I
An examination of the 45 test results filed by Coleman's shift reveals that 30 were signed by Coleman or performed while he was assigned to the control room panel.16 Ten of those tests were performed in violation of the test procedure or were inaccurate on their face.17 In addition, three tests were i h
performed while the faulty makeup tank level transmitter was supplying data to the computer.18 I
I i
I l
l l
l
I MARK COLEMAN Six of the tests involving procedural violations contained accounted-for water additions during the course of the test that are difficult to justify. Based on Coleman's testimony, I
these additions were made in an attempt by Coleman and others to manipulate the test results. The manipulation of leak rate l l tests will be discussed later in this report.
1 1
Coleman's willingness to file inaccurate results is understandable, given his attitude toward the procedure. i t
anything below 1.0 gpm was considered a Accordina to him, f satisfactory test.19 He did not believe it necessary to l
avoid water additions during the course of the test despite the warning in the procedure to avoid inventory changes.20 He l l
stated that he understood that Exceptions and Deficiencies should have t.een filed with respect to unsatisfactory leak rate l tests, but he did not follow this approach because he was told to discard al leak rese tests above 1.0 ppm.21 Coleman's lack of concern for the accuracy of leak rate tests he filed is best understood by an examination of two incidents.
I The first involves an occurrence described by Coleman when discussing pressure from a superior to obtain satisfactory leak l l
I l
l l
I I
MARK COLEMAN i
rate test results. He recalled one occasion when he was told by a Shift Foreman, or Shifi: Supervisor, that he had to perform l
l leak rate tests and do nothing else until he obtained a satisfactory result.22 As a consequence, Coleman stated he l kept performing leak rate tests until one just " randomly" l l
occurred which was below 1.0 gpm.23 l
J The second incident concerns a test result filed by Coleman on January 11, 1979, during which a water addition was made. ,
The test reported negative unidentified leakage.24 n is l
clear from a review of plant activities at the time of this
{
test that a number of leaks had been identified and 1
quantified.25 However, in addition to these leaks, plant documentation indicates operators knew of, but, because of the location of the leak, were unable to quantify, a substantial amount of RCS leakage occurring behind the D-ring at the !
pressurizer.26 Other plant instrumentation demonstrated the possibility that unidentified leakage was above 1.0 gpm. In fact, operators working at that time were viewing instrumentation indicating that unidentified leakage might be as high a r, 2.0 gpm.27 Despite these factors, Coleman filed the leak rate test he pt -forced which indicated a negative result.
6-
1 1
MARK COLEMAN J l
Coleman has,no specific . recollection of this test or the events occurrina in the plant at the time.28 He cannot ?
I explain why leak rate test procedures governing the avoidance I of water additions and the measurement of identified leakage were not followed.29 He ' insisted that at no time did he ever believe the plant was experiencing unidentified leakage in excess of 1.0 gpm.30 l
Both these incidents demonstrate Coleman's attitude ioward I the filing of accurate leak rate test results. He filed
]
satisfactory test results without meaningful evaluation as to ,
1 l their accuracy.
l i
(
l As indicated previously, Coleman also filed test results that were obtained with the faulty makeup tank level transmitter supplying data to the computer, or was operating the control room panel when such tests were performed.31 However, a review of Coleman's leak rate tests during December 1970 and January 1979, when the transmitter problem : was most prevalent, indicates he had a practice of performing leak rate tests using the accurate transmiter.
There are tests which were either performed by Coleman, or while he was running the control room' panel, when the accurate l i
! MARK COLEMAN l \
l
\
i transmitter is apoarently intentionally switched to the computer for the purpos': of perforraing the leak rate test.32 I
1 \
Despite his failure to r err embe r , it appears from the test j i
data that he was aware of the transmitter problem. The test
]
performed by him on December 11, 1978, reveals that the I
! Gecurate transmitter was deliberately switched to the computer i to perform the test.33 Coleman was not only the performer j but also the Control Room Operator controlling the panel.
Coleman admits that under those circumstances he would most Likely have been the person to switch the transmitter for the test.34 Coleman denies any effort to switch transmitters to manipulate test results.35 There appears to be only one case in which Coleman, after having knowledge of the transmitter problem, filed the result of a test which was performed with the inaccurate transmitter. This test, identified in MPR's analysis, was filed on December 21, 1978.36 Coleman's knowledge of the problem with the transmitter prior to the l 1
running of this test is suggested in a December 20, 1978, ;
I turnover report of Gregory H i t. z , his shift Supervisor.37 That report clearly states that makeup tank level transmitter !
- 1 was marked out of service. In addition, Coleman apparently l
l 1
j MARK COLEMAN f 1
knew the one transmitter was faulty because he had deliberately switched to the accurate one on December 11,.1978.38
)
i Manipulation of Test Results l
l Coleman test.ified that he added hydrogen and water during
! the course of. leak rate tests in an effort to manipulate the )
results. There is strong circumstantial evidence that -others l cn his shift, particularly Dennis Olson, knew of, or participated in, the water addition method'of manipulating leak -
rate test results.
Coleman admitted addinq hydrogen during the course of leak-rate tests in an effort to manipulate the results.39 He i
stated that he heard of this method from Harold Hartman.
Coleman conceded that he knew the effect of hydrogen on makeup tank level indication was caused by pressure change in 'the makeup tank.41 Coleman had no specific recollection of when or how many ;
times he used this method.42 A review .of the leak rate test data reveals at least two occasions when Coleman may have been <
involved in adding hydrogen during the course of the leek rate tests.43 Cf those two, only the alleged hydrogen addition of
MARK COLEMAN 1 I
February 14, 1979, was effective in reducing the unidentified I leakage result.44 This is the same time period when members l 1
of other shifts were also addina hydrogen to affect test )
l results.
l l
l Coleman repeatedly stated he could not now recall whether anyone else was aware of hydrogen's effect on leak rate l l tests.45 He believes it possible that he discussed this with Dennis Olson; but he is not certain.40 l Coleman was questioned about his knowledge or participation in other methods of leak' rate test manipulation. A review of the leak rate test data for Coleman's shift revealed that the i
last 11 tests performed between February 25, 1979 and March 13, 1979, all contain accounted for water additions shortly before j the end of the test.47 Coleman admitted that the water was added deliberately in an effort to manipulate the test result by taking advantage of the effect pressure change had on makeup tank level.48 Coleman stated he learned of this method of manipulation from a control room operator on another shift 49 However, he could not identify who it was that advised him of the method.50 He believed that the timing of the addition during
-]
MARK COLEMAN 1
1
-i '
the course of the test was important' in ' obtaining the desired 1
result. If the addition was not close to the end of. the ,
s 1
-test, he believed it would not have the desired effect en the i test result.
When . questioned whether others knew of, or participated r
l with him in, this practice, Coleman again stated he bad no-j present recollection of anyone else participating.53 When specifically asked whether Dennis Olson knew. of the practice, he said he could not be certain whether Olson was aware of the
-practice. But he had - a vague recollection of discussing
! some form of test manipulation with him.55 Coleman had nc recollection of whether his superiors were aware of his conduct. However, he stated he did not believe he would be disciplined if they found out about his test manipulation. ]
I A review of the plant documentation pertaining to. the leak rate tests performed on Coleman's shift indicates that it is l
unlikely he participated alone in the water addition method' of manipulating leak rate test results.
- [ corrected 1/17/86) 1
{
K . {
j
\ j MARK COLEMAN 1 the course of the test was important in obtaining the desired r sult.51 If the addition was not close to the end of the test he believed it would not have the desired offect on the i
test r sult.52 1
When qu stioned whether others knew of, or . participated with him in, his practice, Coleman agaiin stated he had no present N
reco11ec ion of anyone else participating.53 When .l specifically asked hether Dennis Olson knew of the practice, I he said he could not e certain whether Olson was aware of the practice.54 But he had vague recollection of discussing it with him.55 i
Coleman had no recollection of whether his superiors were aware of his conduct.56 Howeve , he stated he did not believe he would be disciplined if hey found out about his test manipulation.57 A review of the plant documentation perta'ining ' to the leak rate tests performed on Coleman's shift indic es that it is unlikely he participated alone in the water addit n method of manipulating leak rate test results, i
a
~
q l
l l
I l
l MARK COLEMAN j On January 11, 1979, the first accounted-for water addition l
i durina the course of a leak rate test occurred on Coleman's shift.N He was the test performer while Olson was the Control Room Operator operating the control room panel.
Testimony from numerous members of the Operations Department H I
makes it clear that water was usually added to the system - by l
the Control Room Operator controlling the panel.b9 l l
l The next water addition appears on February 16, 1979.60 ..
On that occasion, Olson was performing the test while Coleman I
was controlling the panel.
Thereafter, 11 tests containing logged water additions in February and March were performed on as many of Coleman's.
consecutive assigned shifts.61 In each case, the water addition was made near the end of the test, suqqesting some degree of collaboration between the operator assigned to the panel and the operator performing the test. Coleman and Olson performed all of these tests, sometimes with cssistance from Wrignt.
- It is likely that all the members of Coleman's shift were well aware that they were the only shift obtaining satisfactory results during this period.
l l
1 l.
i MARK COLEMAN I
It should be noted that Olson. denies knowledge of adding j hydrogen or water during the course of leak rate tests in an ;
effort to manipulate the results.62 This test data makes it clear that it is unlikely Coleman !
i acted alone when making logged water additions durino the l course of the leak rate test in an effort to manipulate results. The evidence also makes it clear that Coleman had to be aware of the participation of others during this period, I
( l although he insigts he does not recall at this time.
)
l l
Operator Response to Indications of Excessive Leakage i Despite Coleman's failure to recall details about his j actions 'during periods of time when there were indications of I
excessive unidentified leakage, it is clear that he failed to tske appropriate action in response to such indications. He attributes this failure to his misunderstanding of the requirements set forth in the Technical Specifications as to f
l when it was necessary to enter the action statement and his attitude about the. significance of leak rate- test results as a measure of actual RCS leakage, l-1
i l
l MARK COLEMAN f
Coleman testified that the leak rate test was the means used by operators to insure compliance with the Technical Specifications on RCS leakage limitations.63 He stated he
-belfsved in 1978 that he did not have to enter the action j statement set forth in Tech Spec 3.4.6.2 unless 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> had expired from the time of the last satisfactory test result.64 ;
Coleman stated he ran leak rate tests every shift and when' I tests above 1.0 gpm of unidentified leakage were obtained, it would not require doing anything other than looking for leaks.65 According to him, the necessit.y to begin shotduwn of the plant would occur only when it was not possible to obthin a satisfactory leak rate test result within the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />.66 1 i
Coleman conceded that there was nothing in the Tech Specs l
which appeared to allow for this interpretation.67 He stated he adopted this interpretation as a result of direction to do so from others.68 However, he had no recollection of who advised him of this.69 l
l Coleman believed that this interpretation of the Tech Specs evolved because there was little confidence in the test results, 'and that it was the standard routine follcwed by operators.70 I
l l
q l
MARK COLEMAN I a Although Coleman conceded that he was instructed to discard I
all unsatisfactory -leak rate test results, . apparently without -
evaluation, he insists he does not recall any period when he
{
believed a test above 1.0 gpm was accurately reflecting actual plant leakage.71 He did not recall ever- being ' concerned about excessive plant-leakage or discussing such a problem with his superiors.
{
i Nevertheless, Coleman was working during two periods when unidentified 6 leakage appeared to exceed 1.0 gpm, and the required action was not taken.
i October 16 - 20, 1978 '
Coleman's shift apparently did not work in the control room on October 16, 1978. However, on October 17, 1978, while his !
i shift was on duty, Coleman performed a leak rate test with an j unidentified leakage result of 2.07 gpm.73 Coleman was shown the data for this test. Although the unidentified leakage result was above - 1. 0 gpm, Coleman had no .
1 specific recollection of the test or events surrounding it. He had no recollection that a test was performed prior '
to his shift with similar results.75 He could not exp2.ain
l MARK COLEMAN 1
why he sioned, but did not file, the test of October 17, 1978, l nor could he explain why the test had not been discarded pursuant to his stated practice.76 1
l Despite the fact that a previous leak rate test result I
indicated that unidentified leakage was in excess of 1.0 qpm during this period, Coleman continued to maintain that he did not recall ever working when he believed that test results l 1
above 1.0 gpm were accurately reflecting plant leakage.
I e
Coleman had no specific recollection of LER 78-62 issued on i f
October 19, 1978.78 Nor does he recall ever being instructed f I that it was necessary to enter the action statement in respor e to all test results showing unidentified leakage in excess of 1.0 qpm.79 I
December 26, 1978 - January 15, 1978 l
The leak rate test performed by Coleman on January 11, as l well as documentation indicating the plant had excessive RCS j leakage during this period, were reviewed with Coleman. The unidentified leakage figure in the test result filed by Coleman ;
i is -0.16 qpm.80 i
i l
1 l.
I
i l
1 MARK COLEMAN Coleman stated he had no specific recollection of'the leak l )
l rate test in question ncr. did he remember that excessive RCS leakage existed during this period.81 A review of company records indicating excessive RCS leakage did not refresh his recollection.82 He did not recall this January period as one where he was concerned about excessive RCS leakage and had no explanations as to why known identified leakage was not 1 t
accounted for in the test of January 11, 1979.
i i
i It was clear from other plant instrumentation that actual i plant unidentified leakage was above 1.0 gpm and that operators working at the time were viewing instrumentation indicating the possibility of 2.0 gpm unidentified leakage. Despite the information, Coleman failed to take appropriate action in response to the leakage indication and filed the negative test result.83 j l
i l
I I
! MARK COLEHAN {
l 1
Coleman 2/5/85, pp. 22-23, 38, 44, 47-48. !
2 Ibid., pp. 38, 44, 47-48, 68-69.
3 Ibid., pp. 32-34, 38-39.
4 Vol. III, Table 2, I Vol. IV (MPR Report) , Appendix K, Text Numbers 202, l 201, 200, 199, 176, 125, 123, 122, 105, 99, 92, 88. i 5
Ibid., Test Numbers 65, 39, 36, 29, 27, 26, 25, 21, 20, TY7 18, 17, 16, 12.
6 Coleman 2/5/85, p. 9.
7 Ibid., pp. 33, 38-39.
8 Ibid., pp. 33-35, 37-38.
9 Ibid., pp. 45-46. (See Ross report, this Volume, for further discussion.)
10 Ibid., p. 38.
11 Ibid., pp. 43-44.
l 12 Vol. III, Table 2.
13 Ibid.
14 Ibid.
15 Vol. IV (MPR Report) , Appendix K, Test Numbers 29, 27, 26, 25, 21, 20, 19, 18, 17, 16, 12.
16 Vol. III, Table 2.
17 Vol. IV (MPR Report), Appendix K, Test Numbers 206, 201, 200, 199, 197, 65, 36, 26, 20, 12.
18 Ibid., Test Numbers 125, 123, 88.
19 Coleman 2/5/85, p. 10.
20 Ibid., pp. 24-25.
MARK COLEMAN l
21 Coleman 2/5/85, pp. 31-32.
22 Ibid., pp. 43-44, 47-48.
23 Ibid., pp. 43-44.
24 Vol. IV (MPR Report), Appendix K, Test Nuniber 65.
25 Vol. III, Table 4. l 26 Shift Supervisor Turnover Notes, January 13, 1979, (Tab 10).
27 Kunder Informal Notes from file " Ops Notes", January 13, 1979, Kunder handwritten note of 1/13/79. (Tab 45).
28 Coleman 2/5/85, p. 82.
29 Ibid.
30 Ibid., pp. 68-69.
31 Vol. III, Table 2; Vol. IV (MPR Report), Appendix K, Test Numbers 125, 123, and 88.
32 Vol. III, Table 2; Vol. IV (MPR Report), Appendix K, Test Numbers 112, 108, 104, 101, 98, 79, 70.
33 Vol. III, Table 2; Vol. IV (MPR. Report), Appendix K, Test Number 101.
34 Coleman 2/5/85, p. 69.
35 Ibid., p. 71.
36 .Vol. IV (MPR Report), Appendix K, Test Number 88.
l l
37 Shift Supervisor Turnover Notes, December 20, 1978 l
l (Tab 10).
l 38 Vol. IV (MPR Report) , Appendix K, Test Number 101.
39 Coleman 2/5/85, p. 51.
I l
HARK COLEMAN 40 Coleman 2/5/85, pp. 51-52.
41 Ibid., p. 53.
42 Ibid., pp. 51-52.
43 vol. IV (MPR Report) , Appendix K, Test Numbers 39, 122.
44 Vol. III, Table 1.
i 45 Coleman 2/5/85, p. 53. i 46 Ibid., p. 53.
47 Vol. III, Table 2.
48 Coleman 2/20/85, pp. 3, 5.
49 Coleman 2/5/85, p. 54.
50 Ibid.
51 Coleman 2/20/85, p. 5.
52 Ibid.
53 Ibid., p. 7.
54 Ibid., p. 8.
55 Coleman 2/5/85, p. 53; 2/20/85, p. 8.
56 Coleman 2/5/85, pp. 63, 86.
57 Ibid., pp. 86-87.
58 vol, Iy (gpR Report), Appendix K, Test Number 65.
59 Olson 10/22/84, p. 8; '
McGovern 2/6/85, p. 96; Coleman 2/5/85, p. 5; Conaway 2/21/85, p. 10; Blessing 4/10/80, p. 4.
60 Vol. IV (MPR Report) , Appendix K, Test Number 36.
l 1
MARK COLEMAN
')
61 yoi, yyy. Table 2; Vol. IV (MPR Report), Appendix.K, Test Numbers 29, 27, l t
26, 25, 21, 20, 19, 18, 17, 16, 12.
62 Olson 10/22/84, p. 10.
63 Coleman-2/5/85,-pp. 12-14.-
64 Ibid., pp. 19-21. I 65 Ibid., p. 19.
66 Ibid.,.p. 20.
67 Ibid., p. 21.
68 Ibid., pp. 21, 23.
69 I Ibid., p. 21. I 70 Ibid.,.pp. 22-23.
71 Ibid., p. 68.
72 Ibid., pp. 68, 80.
73 Vol. IV (VSR Report) , Appendix K, Test Number 148.
74 Coleman 2/5/85, p. 68.
75 Ibid., p. 68. 1 i
l 76 Ibid., pp. 66-67.
l 1 77 Ibid., p. 68.
l 78 Ibid.,. p. 65.
{-
79 Ibid.
80 yol,.Iy (gpR Report) , Appendix K, Test Number 65.
j, 81 Coleman 2/5/85, p. 82.
82 Ibid., pp. 81-82.
83 Ibid., pp. 80, 82.
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MILLIAM CONAWAY). began l employment Edison 1
1
.. .g .;> 3 ,
s Corpany on March ',23, 1973. In.early'1978 his/ worked ~as a TMI-2 '
- ) 9
[
Control Room Operatos, (CRO)1 Unti1 h'e , ' was' promoted ,td the r s r <
., < v positkon 'of Shift Foreman at f!)MI-2 o'r. ( Ma2.ch }2 1$78. 3, ~ 'He
'f, : ,i
/
remained in that- cepacityi up to the acci.'t.I dent. As Shift ,
?> ,1 %
Foreman, he supervised Thucddre Illjes and John Kidwell . . His l Shift Supervisor was Joseph Chwastyk. 5.
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Analysin of employee tast ). j u.6ny, leak rate, test records, and y ] }*d. \
related plant (Eocuments 90 ggests that Conaway as a ' Shift ;
i
.y .1
, <] ' ,,
Foreman < f ailed, both !" individually s.
and as e 'a supervisor, p
to q, ,
uti ize yat l rate tests ' for the' purpose hf measuring reactor -
/r .1 l coolant systems (RCS) le akag'e . He also failed to. insure that s >- a r ! ; t 4
ii i
t ,
j ..
thq(,tequired .,) / action was taken in re@cnsti to 'd ndi' l cat i ons of j i
excessive RCS leakage in January and March oS 1979.
I[. -
- d I i
i 'k 'i-
- /
e
,1
,7 i ..
/
,I Our investigat. ion did not produce a,ufficient evidence to r
support t, h, e coracluni,on that Conaway was involved in, or aware s
,e i,,
of, intentiona!/ man.n)pulation of leak rate .f;est results. These
(- M s /;
findingsarebasedon7thefflowinginformation. T 3
a f 'E
- u 9 4
s
.i i
Y
WILLIAM CONAWAY Supervision of Leak Rate Testing There is substantial evidence that Conaway failed to use the leak rate test to measure RCS leakage.
Conaway acknowledged that it was his responsibility as a Shift Foreman to ensure compliance wi th the. Technical Specifications for measuring RCS leakage. It was his understanding that the leak rate test was the ' required means that was to be used to demonstrate compliance with the Technical Specifications.1 Despite this knowledge, Conaway conceded that the leak rate test was not used for measuring RCS leakage. He admitted that he took no steps to ensure that th e Technical Specifications or the company proceduret pertaining to. RCS leakago were strictly followed.3 He explained that the filing of test results was viewed primarily as an administrative burden that was required by the Technical Specifications.4 Since the leak rate test was not considered reliable, the results were not viewed by Conaway as pertinent to a determination that the plant was operating within safe leakage limits. As far as Conaway was concerned, the operators i
l WILLIAM CONAWAY would find it more helpful to look at other plant indications, such as sump level and makeup tank level, in order to determine whether the plant were operating safely.6 Since none of these methods could provide- an accurate measurement of unidentified leakage, Conaway conceded that he probably never knew if the plant were operating within the limits set forth . in the Technical Specifications. j I
Analysis of plant records and other evidence tends to l
support his testimony. It is clear that the leak rate test j i
results were not trusted by Conaway or his subordinates. l Instead, it is apparent that all unsatisfactory test results were simply discarded, and all satisfactory test results filed, irrespective of the actual plant leakage at the time. J All available evidence supports the conclusion that Conaway participated in and condoned the discarding. of numerous l unsatisfactory leak rate test results while a Shift Foreman at .
TMI-2.
Plant records indicate that Conaway worked a total of 105 shifts from March of 1978 to March of 1979.8 Leak rate tests were filed on only 36 of his shifts during this period.
Thus, despite the company practice of performing leak rate l
l _ _ _ _ . . _ _________________m
i l
WILLIAM CONAWAY l tests on each shift, only one third of the shifts that Conaway j worked produced filed test results.10 Aside from the fact I
that no unsatisfactory test results were ever filed, there are no obvious patterns found in the testing practices employed I
while Conaway was on shift. There are 1. 7erous shifts during most periods that Conaway was working when no test result was filed. The periods in which the fewest tests were fi 'l ed on j l
l shifts worked by Conaway were the first two weeks of January l I
and the last two weeks of March 1979. Our analysis reveals l .that because of excessive leakage, instrumentation problems, and calculation errors in the test procedure, it would have been most difficult to obtain satisfactory results during these periods.3~1 Conaway acknowledged that it.was standard practice on his shift to perform a leak rate test at least once per shift.12 He also admitted that numerous unsatisfactory tests were discarded without any documentation.13 Conaway initially stated, however, that after a leak rate test result above 1.0 gpm was obtained, it was evaluated and compared with other plant instruments.14 Only if plant conditions indicated that the test were inaccurate, would it be discarded. Despite his earlier statement, it became clear by the end of Conaway's testimony that all tests above 1.0 gpm,
'l
)
l WILLIAM CONAWAY obtained within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> from *he . last satisfactory result,-
were discarded without any evaluation as to their accuracy.16 Ultimately, Conaway testified that the only f actor . he evaluated before discarding an unsatisfactory test
. result 'was the " bottom line"; that is, whether unidentified I
leakage was below 1.0 gpm.1 Conaway. explained that his only {
I concern was whether the plant were operating safely. Test j results were not considered meaningful for this determination.18 l
J Conaway testified that test results were generally I discarded by Control Room Operators, although he personally discarded tests as well.19 Conaway further testified that he I J
was certain that his Shift Supervisor, Joseph Chwastyk, was ]
aware that unsatisfactory leak rate tests were being discarded O
as a matter of practice. Conaway based this belief on the fact that Chwastyk was often present and very active in the control room. Chwastyk is no longer employed .by GPU and ,
refused to submit to an interview during the investigation.
In addition to discarding all unsatisfactory test results, it is clear that Conaway ' approved numerous satisfactory test results for filing without any rec 1 concern for their validity.
l 1
WILLIAM CONAWAY Indeed, our analysis of test records reveals that nearly one-third of the tests approved by Conaway were obviously.
inaccurate, were performed with faulty instrumentation, or were in violation of test procedures.21 Given his testimony, it is not hard. to understand how Conaway would have approved'so many invalid tests for' filing.
In this regard, he testified that as a Shift Foreman he did not take any steps to ensure that the-leak rate test procedure was properly performed by Control Room Operators working under his supervision. As far as Conaway was concerned, each operator was individually responsible for compliance with the procedure.22 The only evaluation he made of the test results was for the
[ purpose of determining that the unidentified leakage was below l 1.0 gpm. According to Conaway, it was the normal practice to l 1
approve any test result with unidentified leakage below 1.0 gpm, including negative results.23 This practice would, of course, advance the 12 hour period during which another satisfactory test result was needed.24 Conaway admitted he did not question control Room Operators .
i under his supervision about operator-caused . inventory changes 1
f . .
.] i i
1 WILLIAM CONAWAY
]
made during the course of the leak rate tests.25 Nor did he review strip charts before approving the test results.26
.i' Conaway conceded that, even- when large water additions were m&de during laak rate tests, he would make no effort to determine why such additions were necessary. Furthermore, he stated ' that he was aware that- operator-entered - identi fied leakage was not necessarily. included in test results.28 l
Records pertaining to tests - approved and filed by Conaway
- demonstrate the accuracy of his testimony in this regard.
Several tests containing obviously inaccurate information, or performed during non-steady state conditions, were approved by Coneway. In addition, eight tests were filed on _his shift
~
despite the fact that the results were based on data f rom . an inaccurate makeup tank level transmitter. One-third of the results filed and approved by Conaway recorded negative values for unidentified leakage.30 Conaway was confronted with a number of test results reporting negative unidentified leakage during the mon th of January 1979. Plant data indicates this was a period of high unidentified leakage.32 Despite these indications of high unidentified leakage, Conaway stated it would have been l
i WILLIAM CONAWAY
\
his practice not to have taken steps to evaluate the test i result as long as it indicated unidentified leakage below 1.0 I
33 gpm. {
1 I
l !
approved by l As indicated previously, eight tests were i i
Conaway in which an inaccurate makeup tank level transmitter f supplied data to the computer during the course of the test.
All these tests were filed between December 5, 1978, and January 10, 1979. There were no tests approved by Conaway ,
where the accurate transmitter was switched to the computer for the purpose of performing the leak rate test, although there j had been such tests on other shifts.34 Indeed, the data does not reveal any ef fort on the part of Conaway or his shift to use the more accurate transmitter for the performance of the leak rate test.
There is considerable testimony that knowledge of the makeup tank level instrumentation problem was common in the Operations Department during the period in question. This testimony is corroborated by plant records which demonstrate an awareness of the problem, particularly on the shift supervised by Conaway.
i WILLIAM CONAWAY An examination of plant records reveals three work requests l
l submitted to repc.ir the inaccurate makeup tank level i
l transmitter.36 Two of these requests were submitted by Conaway. The first one was submitted on December 5, 1978, and the second on December 25, 1978.3 In addition, we discovered that there were turnover notes written by Conaway's Shift Cupervisor discussing the problem.38 l
When confronted with the test data reflecting use of the inaccurate level transmitter, Conaway stated he had no present l recollection of knowing about the transmitter problem in 1978 or 1979. He stated that his review of the work requests signed by him, the turnovec notes submitted by his Shift Supervisor, and corresponding makeup tank level strip charts did not refresh his recollection.40 Conaway was shown test data for December 5 and 20, 1978, and January 8 and 10, 1979. After review of the data, he acknowledged that the inaccurate transmitter supplied information to the computer during the tests in question.
He also recognized that if the inaccurate transmitter were used to supply data to the computer, the test result would not have been accurate.42 9
I WILLIAM CONAWAY j
)
i l
After a review of the test data for December 5, 1978, Conaway acknowledged that the faulty transmitter was switched l
l to the computer just prior to the performance of the leak rate test.43 He had no explanation for this.44 Despite this fact, and the repeated filing on his shift of tests performed
{
with the inaccurate transmitter, Conaway stated he had no j i
knowledge of anyone switching the transmitter in order to 4
obtain a more favorable test result.45 I I
Conaway acknowledged it was his duty as Shift Foreman tio l l
ensure that operators under his supervision % re parforming )
leak rate tests using the accurate level transmitter.
1 However, he has no recollection of ever advising his operators l in this regard.47 On the contrary, Conaway stated that given his attitude about the leak rate test, he was not certain that I
he would have taken steps to advise his operators to avoid O
using the inaccurate transmitter for leak rate tests.
Further, since his only concern was whether the test results reported unidentified leakage below 1.0 gpm, he was not sure that he would reject tests that he knew were performed with the l . inaccurate level transmitter.
l l
1 I
I
-I WILLIAM CONAWAY- ]
I Manipulation of Test Results l q
l Our investigation did not produce conclusive evidence that Conaway was involved in the intentional manipulation of leak rate test results.
I Our examination of leak rate test d a t.a reveals that Conaway ]
I approved six tests wherein hydrogen is alleged to have been added during the course of the test. The NRC had originally alleged that there were four improper hydrogen additions and 11 water additions made during leak rate _ tests I 1
l approved by Conaway. During our investigation, however, we determined that two of the water-additions alleged by the NRC ;
were actually hydrogen additions.52 We also discovered an I
additional logged water addition that influenced the outcome of a leak rate test approved by Conaway on March 14, 1979.53 Conaway repeatedly stated that he was not aware during 1978 i that the addition of hydrogen during the course of a leak rate test could affect t? 4 test results.54 . Moreover, he testif.ied that he was not even awara that hydrogen had an effect on indicated makeup tank level. He stated that he i first became aware of the effect of hydrogen additions on leak gate tests during a conversation with Martin Cooper after the g ._
WILLIAM CONAWAY accident. Conaway did not recall the specifics of .the conversation, but stated that he formed the opinion that Cooper must have'been aware of hydrogen's effect on makeup tank . leve11 prior to the accident.56 Conaway denied evet condonir<g the addition of hydrogen to the makeup tank in order to manipulate leak rate test results. He stated that he believed it to be improper to knowingly file a test result w'aen hydrogen had been added in an effort to manipulate it. 8 Although it is clear that Joseph Chws.styk knew that hydrogen addition could affect leak rate t e u r. results, and it appears that Theodore Illjes manipulated tests, there is no direct evidence that Conaway was aware of test manipulation' <
1 through the addf. ion of hydrogen.
The only evidence indicating Conaway might have been aware of hydrogen's effect on leak rate test results is a statement by Chwastyk in his deposition of April 24, 1984. At that t i.m e ,
Chwantyk said, "...I remember, specifice.11y, giving all of my operators direction not to add . hydrogen when they were doing leak rate tests..59 However, Chwastyk's testimony is uncorroborated.
<t; j
I WILLIAM CONAWAY ,
1 1
I l'
When questioned about Chwas tyk 's atatement, Conaway stated
,he had no recollection of Chwastyk advising him not to add by6rogen during the ' course' of. leak rate tests.60 Nor did he recall discussing the possible effect of hydrogen on indicated I
makeup tank level with other operators.61 -]
l When asked to review the data for the tests :with alleged hydrogen additions, conaway acknowledged that in some cases ~the rise appeared similar to that chused by ' hydrogen and in all .
1 i
, cases recognized the rise in strip chart level indication.62 He pointed out, however, that it was not his practice ~to review strip charts before approving the tests.63 Conaway had no specific recollection of the two tests l
performed successively on February 19, 1979.64- Despite . the t
fact that 43 hours4.976852e-4 days <br />0.0119 hours <br />7.109788e-5 weeks <br />1.63615e-5 months <br /> expired between the last satisfactory test result and the first test approved by Conaway'on February 19, l Conaway maintained that the long interval would not have placed i any additional pressure on him to obtain a successful result on a
his shift.65 i
He admitted that the performance of a. second test on February 19, one-half hour after the first test, was unusual, t
i I
l 1
t i
i WILLIAM CONAWAY f 1
I but could think of no reason why sach a test was done.
However, he stated that he had no recollection of approving the q
)
test.66 1
1 None of Chwastyk's recorded comments about performing a j
)
l leak rate test in order to determine the effect of hydrogen
\
additions re f reshed Conaway's recollection of the incident er ,
1 the events surrounding the tests of February 19.67 j l
l l
l In a further effort to refresh his recollection, Conaway l
l Was shown a copy of Chwastyk 's turnover note for that day. The l
note states "At 60" level in MUT & 5 to 6 psig H 2
l overpressure we get good LR."68 Conaway acknowledged that j l
l the note possibly was referring to the second test approved by I
him on February 19. But he contended that he interpreted the l note to mean that if a leak rate test were performed with th e makeup tank maintained at the described condition, a f satisfactory result would be obtained.69 Thic, was the same position taken by Illfes with respect to Chwastyk's turnover note.
It should be noted that Conaway admitted Illjes contacted him approximately three weeks before our deposition of Conaway. They Jiscussed what Chwastyk had said in his
- l. _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I l l l )
I WILLIAM CONAWAY I I
l deposition of April 1984 and the test of February 19 that Illjes was confronted with during his interview. Conaway l l
i contended that Illjes wanted to talk to him because he was W 1
concerned about his failure to recall the test referred to by ;
Chwsstyk in which he may have taken part. Conaway said he told Illjes he had no recollection of any test referred to by ;
I Chwartyk. Conaway contended he did not discuss any other aspect of Illjes' statement to us.
Conaway was shown a copy of his Shift Foreman't Leg for i
February 19, 19'/ P , in which the results of the first test ,
I signed and approved b'y him on that day were crossed out and initialed by Conaway. The results of the second test approved l 1
by Conaway on February 19 were logged. Although the l
results of the first test were initially signed and approved by j Conaway, he had no recollection of crossing out his log !
entry.72 Nor could he recall whether before doing so, he had i
a conversation with anyone as to why it was necessary to perform a second test, i
After reviewing all the documents , Conaway conceded that if the two tests conducted on February 19 by his shift were in fact performed because Chwastyk wanted to test the effect of 1
hydrogen on leak rate tests, it is likely that Chwastyk would i
1 i
l l
WILLIAM CONAWAY have informed him of what he was. doing.74 He also acknowledged that the test performer and panel operator would have been advised as well.
In an effort to explain his lack of awareness that members of his shift may have manipulated leak. rate tests,- Conaway l
pointed out that it was Chwastyk's policy to have him spend i much of his time in the plant. He explained that. Chwastyk spent more time in the control room than he, and assumed substantial responsibility in the area of leak rate testing. 6 f
Our analysis of leak rate test data failed to disclose a -
pattern of unaccounted-for water additions that support a conclusion that Conaway was involved in this type of test i
manipulation. After an examination of test data by MPR, only.
three of the 11 alleged water additions could be ,
confirmed.77 When confronted with the makeup tank strip j charts for these tests, Conaway acknowledged that there appeared to be water additions during the course of some of the tests. Although he had no recollection of - th e tests in question, after a review of the daily logs he stated he could not explain why the additions were made.79 One of these tests was performed on February 12, 1979. When Illjes was-1 i
L____________
l
[
{
i 1
(
, j WILLIAM CONAWAY j l
questioned about this test, he also recognized that water was added but believed he must have added it without being aware I 0
that the test was in progress.
1 i
Conaway stated he was unaware of a practice by operators of I
l adding water to the makeup tank during a test and then not j l
accounting for it in the test result in order to manipulate the test. Conaway made it clear that if he knew water were i added and not accounted for, he would not approve the test. He conceded, however, he did not take any steps as a Shift Foreman to ensure that Control Room Operators under his supervision did not make unaccounted-for water additions.O Our examination of plant leak rate test data reveals that l
l the test approved by Conaway on March 14, 1979, is the only 1
test which possibly fits the pattern of test manipulation by an accounted-for water addition as described by Coleman in his deposition of February 5, 1985.04 After review of the leak rate test data and related documents for March 14, 1979, Conaway conceded that he could not explain why it was necessary to add water during the course of the test. Ee also recognized that the chart indicated more water was added than was- logged. However, Conaway I
WILLIAM CONAWAY i
denied knowing at that time that the makeup tank level strip
- chart would reflect more water than was actually added by the batch controller. He could not explain why such a large amount of water was added, but conceded that he would have approved the test without asking any questions of his Control Room Operators as to why water had been added. He also l
admitted that he did not require the use of a Data Sheet to record the water addition as mandated in the leak rate test l procedure. ;
\ l l l j
t Operator Response to Indications of Excessive Leakage, i
i Our analysis of plant records reveals that there were at l least two periods when Conaway was working when there were indications that unidentified leakage exceeded 1.0 gpm, and the I required action was not taken in response to such indications.
Conaway acknowledged that he was aware that the Technical Specifications required that leakage be monitored to ensure compliance with the limiting condition for operation for RCS leakage. It was his understanding that this was to be done 0
by the performance of a leuk rate test.'0
)
[ corrected 1/17/86]
1
T WILLIAM CONAWAY 1
. den'ed P,nowing at that time that the makeup tank level strip !
chart would reflect more water than was actually added by the batch c ptroller. He could not explain why such a large
\
amount of water was added, but conceded that he would have approved the test without asking any questions of h2- Control as to why water had been added. He also Room Operators admitted that he d not require the use of a Data Sheet - to record the water ad-itions as mandated in the leak rate test procedure.08 Operator Response to Indica ons of Excessive Leakage l
l Our analysis of plant recor s reveals that there were at l
j least two periods when- Conaway ws working when there were "I i indications that unidentified leakage exceeded 1.0 gpm, and the required action was not taken in respons to such indications.
conaway acknowledged that he was aware hat the Technical Specifications required that leakage be moni ored to ensure compliance with the limiting condition for oper tion for RCS leakage.89 It was his understanding that this was to be done by the performance of a leak rate test.90
.I I
l WILLIAM CONAWAY- l l
However, Conaway admitted that the leak rate test was not used to measure RCS leakage on his shift.91 It was regarded j j
I as administrative paper work that had to be complied with once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. He stated th ere was no confidence in test. )
results, and, as a consequence, the test was not used as a
! means to mearure plant leakage.93 l 1 Conaway stated he looked at other plant instrumentation to ]
monitor leakage _ but conceded that nothing other than the' leak rate test could provide the measurement necessary to determine that the plant was within the leakage limits set forth in the' l 94 Further, he admitted that the Technical Specifications reason they monitored the other instrumentation was to ensure-that the plant was operating safely and not- to ensure compliance with the limiting condition _ for operation for RCS leakage.95 Conaway stated tha t he probably never really knew whether unidentified leakage were within the limits required by 96 the Technical Specifications In light of the explicit directions set forth in the action statement, Conaway was asked why he failed to ensure that the required action be taken when leak rate test results above 1.0 gpm were obtained. Conaway expressed the opinion that the failure to properly respond was probably due to a feeling. of
WILLIAM CONAWAY pressure to keep the plant operating.97 However, he did not recall any specific incident when he received.pressurc from his superiors not to take the required action when leak rate tests with unidentified leakage above 1.0 gpm were obtained.99 When questioned about LER 78-62, Conaway had no independent recollection of its contents. Nor did he recall the Operations Memo ' :'s u ed by Floyd on October 17, 1978.99 However, Conaway-stated ' that had he read the LER in 1978, he would have found its provisions dealing with entry into the action statement confusing.100 Conaway believed that the practice of discarding tests and i l I not taking the required action continued even when plant instrumentation indicated that unidentified leakage was above lOl This practice also continued at times when known 1.0 gpm.
leakage could not be quantified.102 ]
December 20, 1978 - January 15, 197.9, Analysis of this period reveals that out of 12 shifts worked by Conaway only four produced leak rate test results.
All the tests approved and filed were performed with the inaccurate makeup tank l'. vel transmitter.103 L
[
1 I
I l WILLIAM CONAWAY l
l It is likely that numerous tests showing leakage in excess l l of 1.0 gpm were discarded during this period. MPR's analysis 1 of leakac,e reveals that other plant instrumentation indicated unidentified leakage 'n excess of 1.0 gpm.104 Plant documentation for this period was reviewed with Conaway. For example, on January 8, 1979, Conaway approved a j
! leak rate test result demonstrating unidentified leakage of !
105 When asked why this test was approved despite
-0.53 gpm.
indications of excessive unidentified leakage, Conaway stated was his practice to approve any satisfactory result it regardless of such indications.106 data for January 9, 1979, was also reviewed by Plant Conaway. He was working on that date and no test was filed by his shift. It appears that other plant instrumentation )
indicated unidentified leakage above 1.0 gpm. After a review data, Conaway stated that because there was an of this indication of leakage, it would have been his practice to However, ';ince there perform a leak rate test on his shift.
was none on file, Conaway believed it possible that any test performed was discarded and the required action not taken.107
WILLIAM CONAWAY March 15 - 28, 1979 Our analysis indicates that unidentified leakage increased during March 1979, until it was close to 1.0 gpm on March 15, 08 However, as and remained fairly constant thereafter.
i discussed in Volume I, Operations personnel would have !
perceived unidentified leakage to be much greater.
During this period, Conaway worked ten consecutive assigned shifts without filing a leak rate test result.109 He had no clear recollection of the period.110 He also did not recall the Temporary Change Notira, which required operators to manually calculate reactor coolant drain tank collection in order to correct an error in the leak rate test procedure. 11 He conceded that the practice of discarding all test results above 1.0 gpm did not change, and that it was likely that, during this period, leak rate tests were performed and discarded even after the hand calculation was made by the operator. There is no evidence to indicate that appropriate action was taken during this period, despite the likelihood that other plant instrumentation was demonstrating the validity of such test results.
b:1 l=
. WILLIAM CONAWAY 1 Conaway 2/21/85, pp. 15-18, 22-23.- i
'1 2 Ibid., p. 19. !
'3' Ibid., p. 16. ]
1 '
4 Ibid., pp. 34-36.
5 Ibid., pp. 34-36.
6 Ibid., pp. 26; 34-35. .,
7 Ibid., p. . 3 5.
8 Vol III, Table 2.
9 Ibid.
10 Ibid. -l 11 Vol. IV (MPR Report),Section IV.
12 Conaway 2/21/85, p. 28.
13 Conaway 2/21/85, pp. 28-29; 3/4/85, p. 15.
14 Conaway 2/21/85, pp. 25-27.
15 Ibid., pp. 27-28.
1 16 Ibid., pp. 28-29, 34.
17 Ibid., p.-93.
18 Ibid., pp. 34-35.
19 Ibid., p. 36. ;
(
20 Ibid., p. 36.
21 Vol. III, Table 2.
l --
22 Conaway 2/21/85, p. 16.
L.
l 23 Conaway 2/21/85, pp. 23-26, 80-81, 90,.93; 2/25/85, pp. 7-8.
l 1
l
p ,
'i WILLIAM CONAWAY-
'24 conaway 2/21/85, p. 23.
35 Conaway 2/25/85, pp. 3-4.
26 Ibid., p. 6.
27 Conaway 2/25/85, p. 37.
28 Conaway 3/4/85,.p. 5. < I 29 Vol. IV (MPR Report), Appendix K, Test' Numbers 113, H 111, 100, 82, 71, 68, 67, 66.
30 Vol. III, Table 2. .
31 vol. IV (MPR Report), Appendix K, Test Numbers 71, 68, :i,
- 67. '!
32 Ibid., Figure IV-20. i l
33 Conaway 3/4/85, pp. 4-8. l 34 Vol. III, Table 1.
35 Vol. III, Table 4; ;
Adams 3/8/85, pp. 47 I 3/13/85, pp. 140-141; Faust 2/19/85, p. 16; .f 2/20/85, pp. 18-21; j Frederick 3/14/85, pp. 66-67, 71, 103-105; d Guthrie 2/12/85, pp. 16-17, 61-62; McGovern 2/6/85, pp. 34-37, 70-71, 86; A. Miller 3/20/85, pp. 86-87.
36 Vol. III, Table 4.
l' 37 Ibid.;
TMI-2 Job Ticket Nos. C0345 12/25/78, C0013 12/5/78, (Tab 7).
38 Vol. III, Table 4. !
39 Conaway 2/21/85, p. 66'.
I' 40 Conaway 2/21/85,-pp. 67, 82; '
3/4/85, p. 5. j j
I )
1 L ,
l . . . . . . .. .. - . . .
WILLIAM CONAWAY
- 41. Conaway 2/21/85, pp. 81-83, 90-91; 2/25/85, pp. 7-8, 10-11.
42 Conaway 2/21/85, p. 89; 2/25/85, p. 9.
I 43 Conaway 2/21/85, pp. 83, 89.
44 Ibid., p . 8 9 .'
45- .Conaway 2/21/85, pp. 69-70; 2/25/85, p. 9.
46 Conaway 2/21/85, p. 68.
l 47 Ibid., p. 68.
48 Ibid., p. 93.
49 Ibid., pp. 80-81, 89-90.
50 Vol. IV (MPR Report), Appendix K, Test Numbers 134, 89, 39, 35, 34, 33.
51 Ibid., Hydrogen additions: Test Numbers 134, 89, 39, 35; Water additions: . Test Numbers 130, 100, 87,.71, 67, 66, 44, 43, 35, 34, 33.
52 Ibid., Test Numbers 34, 33.
53 Ibid., Test Number 11.
54 conaway 2/21/85, pp. 73-74; 2/25/85, p. 34.
55 Conaway 2/21/85, p. 70.
56 Ibid., pp. 70-71.
57 Ibid., p. 74, 58 Ibid., p. 75.
59 chwastyk 4/24/84, p. 35. j 60 Conaway 2/21/85, p. 73.
1 l
1 WILLIAM CONAWAY !
l )
I f l 61 Conaway 2/21/85, p. 74- ;
2/25/85, p. 18.
l 62 Conaway 2/21/85, pp. 78-80; ;
J l
2/25/85, pp. 13-21.
! i 63 Conaway 2/21/85, p. 80.
64 Conaway 2/25/85, p. 22.
i 65 Ibid., p. 20. l 66 Ibid., pp. 21-22. >
l 67 Conaway 2/21/85, pp. 70-74.
68 TMI-2 Daily Report Plant Status Report and Shif t Supervisor l Turnover Notes February 19, 1985, (Tab 10). I 1
69 Conaway 2/25/85, p. 31.
70 Conaway 2/21/85, p. 83. )
71 TMI-2 Shift Foreman Log, February 19, 1979, (Tab 49).
72 Conaway 2/25/85, pp. 22-26.
73 Ibid., pp. 23-24.
74 Ibid., p. 32.
75 Ibid., pp. 32-34.
76 Conaway 2/21/85, pp. 4-7, 12, 43.
77 voi, Iy (gpR Report), Appendix K, Test Numbers 87, 44. 43.
78 Conaway 2/25/85, pp. 2, 12-13.
79 Ibid., pp. 2-3, 12-13.
80 Illjes 2/11/85, pp. 31-34.
81 Conaway 2/25/85, p. 13.
82 Ibid., p.4.
83 Conaway 2/25/85, pp. 3-4.
I l
1 k
WILLIAM CONAWAY 84 Vol. IV (MPR Report), Appendix K,. Test No. ll; Coleman'2/20/85i pp. 3-4. ,
l 85 conaway 2/25/85, p. 36. l l
86 - Ibid., p. 36.
87 Ibid.,. p. 36.
'88 Ibid., pp. 36-37.
89 Conaway 2/21/85, pp. 17-18. .
1 90 Ibid., pp. 18, 22-23.
91 Ibid., p. 19.
92 Ibid., pp. 34-36. j j
93 Ibid., pp.'34-35. 1 I 94 Ibid., pp. 21-22, 35.
95 Ibid., pp. 34-35.
96 Ibid., p. 35.
97 Ibid., p. 37. l 98 Ibid., p. 37.
99 Ibid., pp. 45-47.
100 Ibid., p. 47.
101 Ibid., p. 44. ;
i 102 Ibid., p. 44.
103 vol. IV (MPR Report), Appendix K, Test Numbers 71,,68, 67, 66.
104 ' Ibid., Figure IV-20.
105 Ibid., Appendix K, Test Number 67.
106 Conaway 3/4/85, pp. 7-8.
l t
1
. . . . - - - . - - ----------a- - -.- - - - - - - -
4*
WILLIAM CONAWAY "I
2 5, p. 4.
108 Vol. IV (MPR Report), Figure IV-20.
109 Vol. III, Table 2.
110 Conaway 3/4/85, p. 15.
111 Ibid., p. 14.
112 Ibid., pp. 15-16.
I l'
l JOSEPH R. CONGDON is presently employed by GPU Nuclear Corporation at TMI-2 as a Shift Foreman. In 1978-3979, prior to the accident, he was a Control Room Operator at TMI-2.
During this period he normally worked in'the control room with ;
Charles Adams was his Shift !
! Martin Cooper and Mark Phillippe. i Foreman and Brian Mehler was his Shift Supervisor. y Analysis of employee testimony, Feactor Coolant Inventory Balance tests Ileak rate tests), and related plant documents, suggests that 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 l indications of excessive RCS leakage in October 1978, January and March 1979.
1 l
Congdon himself admitted that he knowingly engaged in the l manipulation of leak rate tests while an operator at TMI-2 by hydrogen to the makeup tank. Furthermore, his adding 5
testimony, together with plant recordr, implicates others on his shift in the same practice.
l l
l
[ corrected 1/17/86]
JO PH R. CONGDON is presently employed by GPU Nuclear Corporati' n at TMI-l as a Shift Foreman. In 1978-1979,- prior to the acc dent, -he was a Control . Room Operator at TMI-2.
During this pe iod he normally worked in the control room with Martin Cooper an Mark Phillippe. Charles Adams was his Shift Foreman and Brian.M hier was his Shift Supervisor.
Analysis of employe testimony, Reactor Coolant Inventory Balance tests (leak rate sts), and related plant documents, '
suggests that Congdon failed o properly utilize the leak rate- ,
test for the purpose of measuri g reactor coolant system (RCS) j l '
leakage and also failed to take re uired action in response to j indications of excessive RCS leakage in October 1978, January and March 1979.
Congdon himself admitted that he knowin y engaged in the manipulation of leak rate tests while an opera or at TMI-2 by .
adding hydrogen to the makeup tank. Furt ermore, his testimony, together with plant records, implicates others 'o n his shift in the same practice.
i
i l
JOSEPH R. CONGDON il These conclusions are based on the following information. l Utilization of Leak Rate Tests to Measure Leakage Congdon testified that he regarded the filing of leak rate- l tests primarily as an administrative burden that had to be :
completed because it was required by Technical Specifications (Tech Specs) as the means to measure RCS leakaqe.1 He did not believe that the test results were reliable or related to plant safety.2 His attitude about the test became reinforced l as it became more difficult to obtain a satisfactory (below 1.0 qpm) leak rate test result.
f Analysis of plant records makes it clear that this attitude gesulted in a failure to properly utilize the leak rate test in order to measure RCS leakage.
Between March 22, 1978, and March 28, 1979, Congdon worked 1
approximately 122 shifts during which a leak rate test could have been performed.4 Despite this fact, only 52 tests were filed on shifts on which Congdon was working.5 Congdon signed as the performer on 17 of these tests and was assigned ;
to the control room panel for approximately half of the others.6 JOSEPH R. CONGDON The' testimony of Congdon and others makes it clear that the-failure to file tests on many shif ts ' resulted from a practice at TMI-2 to discard all test results demonstrating unidentified' ]
leakage in excess of 1.0 gpm.7 i
Discar6ing Test Results It appears from both the testimony and plant records that Congdon participated in the systematic discarding of all leak rate tests demonstrating unidentified leakage in excess of 1.0 qpm. He admitted that it was the practice on his shift to discard all unsatisfactory leak rate tests showing unidentified i leakage above 1.0 gpm.0 Congdon stated it was the practice on his shift to perform leak rate tests at least once per shift.9 As it got closer to the time period of the accidenti and it became more difficult to obtain a satisfactory result, it became necessary to increase the number of tests performed during a shift.10 When questioned recarding the evaluation of leak rate test results, Congdon initially stated that, in every case in which an unsatisfactory test could not be declared invalid because of operator errors, an evaluation was made before the test was 1
l JOSEPH R. CONGDON i
discarded.11 'The unsatisfactory test would be given to the Shift Foreman.12 Another test would be initiated, plant instruments would be examined, and a search for leaks would be instituted.13 Any leakage found would be accounted for in the results of the next test.14 If the results of the second I
test were below 1.0.gpm, the second test would be filed and the I first test would be discarded.15 He further stated that, on
(
those occasions where it was not possible to obtain a subsequent satisfactory test on his shift, the unsatisfactory I
test would be turned over to the incoming shift by his' Shift l
Foreman.16 He was certain that whenever a test result showed unidentified leakage in excess of 1.0 gpm, a search for leaks took place.1 He acknowledged that searching for leaks was a time-consuming practice.10 l
His testimony in this regard conflicted with his ' earlier testimony that as it got closer to the accident, it was necessary to run several tests on each shift in order to obtain satisfa'ctory results.19 Obviously, if numerous tests had to be performed before a satisfactory result could be obtained, it would become difficult to search for leaks after each test.
After a brief recess in the deposition, Congdon's counsel stated that Congdon had misunderstood the questioning on the I '
I l
l l JOSEPH R. CONGDON issue of discarding unsatisfactory leak rate tests.20 Congdon then admitted that as it became more difficult to
~
obtain satisf actor's test resu1ts, his shift would perform as j many tests as possible.21 i
l According to Congdon, the practice of searching for leakage l l
was abandoned, unless it was close to the expiration of the 72-hour time period since the last satisfactory test result.22 It became an accepted practice to -simply discard all test results showing unidentified leakage in excess of 1.0 .,
gpm.23 He admitted that this would occur even during time periods when other plant instruments indicated that unidentified leakage was above 1.0 gpm.24 As stated previously, plant records support Congdon's testimony. A review of leak rate test data for periods when Congdon was working reveals leak rate tests were not filed on over half the shifts. The longest periods of time between the filing of satisfactory leak rate tests occurred in January and March 1979.25 These were periods when increased unidentified leakage and errors in the test procedure made it more difficult to obtain satisfactory leak rate test results.
5-
1 1
JOSEPH R. CONGDON i
I l
In licht of Congdon's admission that he discarded tests I without evaluation, he was asked to review his April 1980 i
l statement to the NRC wherein he den!ed throwing away E
i unsatisfactory test results. He stated that as a result of i having had more time to think about this issue, he now realizer 1 i
that what he told the NRC then about the practice of discardino i leak rate tests was not completely accurate.26 Contrary to what he said in 1980, there were indeed times he discarded j unsatisfactory leak rate tests which had been performed properly and were otherwise valid.27 l
Filing Inaccurate Test Results In addition to discarding all unsatisfactory test results, l
it is clear from Congdon's testimony and related test data that I
it was the practice on Congdon's shift to file satisfactory leak rate test results without regard for their accuracy.28 j i
More than half of the tests submitted with which Congdon was ;
involved were either invalid on their face, run on faulty i
instrumentation, or otherwise performed in violation of testing l procedures.29 {
l l
When Congdon was questioned about whether he evaluated I
satisfactory tests before he filed them, he testified that for i 1
l l
i
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l l
JOSEPFI R. CONGDON l l
i i
a period of time, some evaluation was made of the accuracy of leak rate tests showing leakage below 1.0 gpm.30 According to Congdon, this practice ceased once it became difficult to obtain satisfactory leak rate test results.'31 Thereafter,
' I according to Congdon, the practico developed of filing all i satisfactory tests inclutlino those yielding negative results.32 Congdon's testimony regarding the evaluation of test
- results is not entirely consistent with plant records. These records suggest that the practice of filing inaccurate results on Congdon's shift existed right from the beginning of the plant's operation and continued up through the accident. About !
one-third of the tests filed on Congdon's shift prior to December 1978 contained obvious inaccuracies on the face of the test printout, or were performed when the plant was not at steady state.33 In December 1978 and January 1979, while Conodon was working, several inaccurate leak rate tests were filed which were performed with a faulty makeup tank level transmitter supplying data to the computer.34
- ~.
l iTOSEPH R. CONGDON Congdon testified that the problem with the transmitter was common knowledge in the Operations Department and that it was his practice to perform leak rate tests using only the accurate makeup tenN level transmitter.35 i
Further, Congdon's awareness of the problem at this time is l evidenced by leak rate tests that he performed, or was aware of, where the accurate level transmitter was switched to the ,
computer specifically for the per f o rniance of the test.36 l
This practice of switchina to the accurate transmitter is consistent with Congdon's testimony regarding his conduct under these circumstances.37 There are test records, however, which demonstrate that on other occasions, Congdon did utilize the faulty makeup tank level transmitter during the test, despite his knowledge of the ]l problem.38 l I
An examination of the test filed by Congdon's saift on December 30, 1978, is further evidence of Congdon's knowledae of the transmitter problem and his willingness to file test results perfo'rmed on the inaccurate transmitter.' This test was filed shortly before the expiration of the 72-hour time period for obtaining a satisfactory leak rate test. Althouah 1
UOSEPH R. CONGDON i
the test was started by the previous shift, it appears that ]
Congdon, who controlled the panel, switched the inaccurate transmitter from the computer to the chart immediately upon the I
conclusion of the test. Thus, despite his apparent knowledge l that a leak rate test was performed on the inaccurate i transmitter, the test result of -3.8 gpm was filed as a
- satisfactory result.
l l
i J
l There is further evidence that, after Congdon was aware of J l
i l the transmitter problem, he performed and filed at least one l l
leak rate test using the inaccurate level transmitter.40 This test result showed unidentified leakage to be below .0 !
gpm, and was filed on January 5, 1979, during a period when plant instrumentation indicated unidentified leakage was exceeding 1.0 opm and operators were having difficulty obtainino satisfactory leak rate test results.41 When questioned about this test, Congdon stated he could not tell with certainty that the chart trace indicated a transmitter problem. However, he conceded that the difference between the transmitter readings appeared abnormal.42
[ !
i l
JOSEPH R. CONGDON Manipulation of Test Results
! Based on Congdon's testimony and plant documentation, it is clear that he manipulated the results of leak rate tests by adding hydrogen during the c>urse of the tests. There are indications that others on his shift, including the Shift Foreman, knew of or participated in this practice. Although it is possible that other methods of manipulating test results l
l were used, there does not appear to be a clear pattern of I intentional manipulation by use of methods other then hydrogen 1
additions. ]
)
1 To determine the extent to which Congdon participated in
]
the manipulation of test results, his prior statements on the subject, as well as relevant leak rate tests and plant documents, were examined.
Questions concerning improper hydrogen or water additions during several leak rate tests have been raised by our investigation and in earlier NRC allegations. Of the 52 tests filed on shifts worked by Congdon, 24 tests were the subjects of such allegations.43 In 17 of those tests, Congdon was either the test performer or the control room operator assioned to the panel.44 Of these 17 tests, 12 are alleged to have 10 -
I l i 1 l
JOSEPH.R. CONGDON l l
\
unaccounted-for water additions.40 One test contains a series of accounted-for water additions similar to a pattern of manipulation found on another shift.46 It has been alleged that hydrogen was added during the coarse of six of the 17 tests. .Three of the six alleged hydrogen additions are contained in tests between February 15 and March 2, 1979.47 l
Congdon was questioned about his knowledge in 1978 and 1979 of the effect hydrogen additions had on makeup tank level indication. He admitted that he became aware, at some point during 1978 - 1979, that hydrogen additions did have an effect on makeup tank level indication.48 i 1
Congdon stated that he recalls discussing the possible l 1
effect of hydrogen on makeup tank level with other members of '
his shift.49 As a result, they decided to test the effect of ;
hydrogen on leak rate test results. A leak race test was l-i performed and hydrogen was added during the course' of the f
test. He recalled that the makeup tank level strip chart was marked at the point where hydrogen.was added.50 i
11 -
i JOSEPH R. CONGDON Congdon does not' specifically recall that' he recognized )
)
hydrogen's effect on makeup tank level prior to performing the experimental test. He admitted adding hydrogen before the experiment but believes he did not observe its effect on level indication.52 However, he was certain he added hydrogen to maniculate leak rate test results after the experiment.53 Congdon conceded he filed those test results even though they l were possibly inaccurate.54 He did not believe that in doing -
so he was operating the plant in an unsafe manner; because, as l an operator, he used other plant instrumentation to determine ,
I whether there were serious leakage problems.55 As further
! justification for his actions, he stated that they were concurred in by his Shift Foreman.56 He stated that he and l others were of the opinion that they were simply taking 1 ,
l advantage of a "clitch" in the system since the addition of I hydrogen during leak rate tests was not specifically prohibited.57 l Congdon did not recall making a consistent or planned effort to add hydrogen everytime he performed a leak rate test.58 Moreover, it is his recollection that the effect was not always consistent.59 Congdon stated the practice occurred more often when there wan difficulty in obtaining satisfactory leak rate test results.60 l
JOSEPH R. CONGDON Congdon was questioned about the involvement of other Operations personnel in the practice of adding hydrogen during the course of leak rate tests to manipulate test results. He stated that he #irst learned of the possible effect hydrogen i
had on leak rate tests from operators on other shifts durina j the course of turnovers.61 Congdon was questioned specifically about the experiment he performed while on shift and who participated in that experiment. He admitted that he was the individual who 1
controlled the panel during the experiment and believes that his Foreman, Charles Adams, participated with him.62 1
l Although he is not certain, he stated that the notation on the )
1 l makeup tank strip chart, which refers to the addition of l hydrogen, was made by Adams.63 Although he had no clear recollection, he believes that the test performer would have been part of the effort to conduct the experiment.64 However, he stated that it was not likely that the experiment was communicated to the Shift Supervisor or anyone else in upper management.65 Congdon was asked whether other people on his shift were aware that he was adding hydrogen after this experiment in an effort to manipulate leak rete test results. He stated that,
I l JOSEPH R. CONGDON after the experiment, he added hydrogen on a number of occasions to manipulate tests and that most likely Martin Cooper and Adams were aware of this fact.00 Congdon's - belief j that others were aware of what he was doing is based on the following factors: l I- 1. Although he does not recall the specifics of any discussion with Adams, he believes that they had 4 conversations about the use of- hydrogen during the -!
tests to manipulate the results. He stated these conversations most likely occurred when there were long periods of time between successful leak rate tests;67 ;
- 2. He recalls not making any effort to conceal what he was i t I doing from anyone;68 and I
l
- 3. As a crew, they were very close and they communicated ;
with each other regarding what they were doing and the reasons for their conduct.0' l
Congdon was specifically questioned regarding whether Brian Mehler, his Shift Supervisor, knew that he was adding hydrogen during the course of the leak rate tests in an effort to l 1 rnanipulate test results. Congdon stated he had no specific l
I l
I l
l JOSEPH R. CONGDON recollection, but it was his opinion that his Shift Supervisor must have known since there was no effort made to hide what he l was doing. He does not know if Adams advised Mehler as to what was being done.70 I Congdon's testimony about the practice of adding hydrogen ,
j is consistent with our examination of plant records. After a review of the date for the leak rate test'of February 15, 1979, he stated that this test was probably the one perf ormed 'in order to experiment with the effect of a hydrogen addition on makeup tank level indication.71 The strip chart for this test bears the notation " Pressurized MUT," referred to by I Congdon. 2 iwo oL the next three leak rate tests performed
' l on Congdon's shift have suspected or confirmed hydrogen additions.73 Those additions coincide with similar action by.
other shifts during the same time period.74 Further, these l additions occurred when it was becoming more difficult to
]
obtain satisfactory leak rate test results.75 Faulty makeup j i
! tank level instrumentation permitted the . addition of - hydrogen 6
to have the described effect on level indication.
i These factors support Congdon's assertion that before the experiment in February he had no clear understanding of hydrogen's effect on leak rate tests. Prior to thic period, l
l JOSEPH R. CONGDON there is no pattern of additions, nor does it appear that the additions had the clear effect on MUT level which was present in February.77 l l
i Congdon was questioned regarding his awareness or use of rate test results. He I i
o t.he r methods to manipulate leak indicated that he was not aware of any other method.78 He was specifically asked whether he was familiar with the f
l practice of " jogging water" into the makeup tank durina the l course of leak rate tests in 1978. He indicated he was not aware of that concept in 1978-79, but did became aware of it as a result of conversations with the NRC and counsel which occurred after the accident.79 With respect to unicaged water additions, Congdon stated that in 1978 it was his practice to make every effort not to add water to the makeup l tan'; during the course of leak rate tests.80 For the most part, this testimony is supported oy a review 0: the plant leak rate test data. Some of the NRC allegations of unlogged water additions resulted from a mistaken reading of the makeup tank level strip chart times.81 Others could not be substantiated because the makeup tank strip chart trace was erratic as a result of the inaccurate transmitter supplying the data to the strip chart.82 We were not able to confirm any
- 16 -
l 1
JOSEPH R. CONGDON of the alleged unaccounted-for water additions during tests run by Congdon or when he controlled the panel. We did not find any clear pattern of manipulation by means of unaccounted-for to the pattern of hydrogen addi-l water additions similar I tions.83 l
l l l
l he was aware prior to the l Congdon was asked whether l
accident that some operators were intentionally manipulating {
I t leak rate test results by adding water and accounting for it at a time when the makeup tank level transmitter provided a false l
level indication similar to that created by hydrogen addi- .
J tions. Congdon stated that he was not aware of this prior to the accident.04
-__Operatcr Response to Indications of Excessive Leakage Plant records suqqest that there were at least two periods when Congdon was working when there were indications that unidentified leakage exceeded 1.0 gpm. i
)
l examining Congdon's action in response to ir d i-Before cations of excessive leakage, it should be pointed out that he cSated that he believed Tech Spec 3.4.6.2 requir ed. the imple- i mentation of the action statement only if a leak rate test JOSEPH R. CONGDON result below 1.0 opm was not obtained within the 72-hour time in the procedure.85 In addition, he period set forth admitted that, during periods when it was difficult to. obtain I satisfactory test results, it was the practice to discard all te.sts with results above 1.0 gpr.86 l
October 16-22, 1979 The record indicates that Congdon's shift was off duty on -;
j October 16 and 17, 1978. On October 18, 1978, Congdon's shift performed four leak rate tests.O The first two 'were l
unsigned and not filed. The results of each were above 1.0 opm.88 These tests were among those viewed by the NRC 1
Inspector on October 18th.89 Congdon had no recollection of the tests.90 He believed, however, that the number of tests
.)
performed on his chift was more than usually necessary to )
obtain a satisfactory result.91 i Congdon had no recollection of taking any steps to respond to excessive RCS leakage daring this October period.92 He believed if the action stat 9 ment nad been entered,.there should i
have been not.a tions in the logs to that effect.93 He had no recollection of the practice of rounding off leak rate test j results or that this was purported to be the way the Company-l 1
)
JOSEPH R. CONGDON I
reduced the unidentified leakage to within acceptable limits on October 18, 1978.94 Congdon was specifically questioned about his knowledge of I LER 78-62. He had no recollsation of the LER but believed he must have known about it'at that time since he signed ' the PORC action item list.95 Congdon was certain that the LER did not alter the practice with respect to entry into the action stateraen t as a result'of l leak rate test results above 1.0 qpm.96 He continued to view I
! l it necessary only to enter the action statement if it were not !
possible to obtain test results below 1.0 gpm within the 72-hour period referred to in the procedure.97 Congdon was asked whether he recalled any meetings or discussions with superiors about the LER and how it was to be interpreted, particularly with respect to the retention of test results above 1.0 gpm and entry into the action statement. He had no recollection of any briefing about its contents, andfit is his opinion today that the only thina that occurred with rekpect to this LER was its circulation.99
JOSEPH R. CONGDON December 26, 1978 - January 15, 1979 Plant documents and records of activities pertainina to.
RCS leakage during the month of January 1979 were reviewed by <
Congdon during our interview. In addition to indicating actual i s
leakage in excess of 1.0 apm, the - documents suggested that .,
numerous tests showing unidentified leakage in. excess of 1.0 gpm were discarded. Af ter this review, Congdon admitted that l 1
although he had no specific recollection of this period, the.
practice at the time would have been to discard leak rate test results above 1.0 gpm without taking the required action.99 occur despite the fact that other plant This would instrumentation a].so ind'.cated unidentified leakage above the l
)
Tech Spec limits.100 i
These records make it clear that during January 1979 the various plant systems used by the operators to determine leakage demonstrated the possibility of leakage above 1.0 gpm.
Both the testimony and records reveal that Congdon's practice s
of'not filing test results above 1.0 gpm and not taking the j i
required action continued during these periods. Test results l 1
above 1.0 gpm were discarded and the action required was not j taken because the 72-hour time period had not yet expired. )
1 l
l f
I JOSEPH R. CONGLON '
March 16 - 27, 1979 t
Analysis of reactor building suinp collection data reveals ,
an increase in the rate of unidentified leakage durina March 1979, until it approached close to 1.0 gpm on March 16, and
)
remained fairly constant thereafter.101 However, for reasons discussed in volume I, operators would have perceived
{
unidentified leakage to be much creater. {
i Conadon apparently was not on shift during the month of March until March 21. Between March 21 and 26, Conadon's shift filed only one leak rate test result, although he was '
apparently working each day.102 This test result was below l 1.0 gpm, chiefly because water additions were made during the j course of the test. Although another shift performed the test, Congdon's shift filed the results. Assumina Congdon's action was consistent with his testimony, all test results above 1.0 l l
opm obtained during this period would have been discarded without takina the required action.
l l
JOSEPH R. CONGDON 1 Congdon 2/13/85, pp. 34, 38-39, 57, 110.
t 2 Ibid., pp. 14-15.
3 Ibid., p. 34.
]
1 4 Vol. III, Table 2. j i
l 5 Ibid. i l 4 l 6 Ibid.; I Vol. IV (MPR Report) Appendix K, Test Numbers 278, 213, 210, 204, 198, 192, 182, 170, 160, 157, 156, 154, 142, l 139, 132, 129, 122, 119, 116, 110, 109, 105, 78, 72, 46, 38, 32, 28, 24, 23, 4.
7 Adams 3/19/85, p. 13; Coleman 2/5/85, pp. 32-33; Congdon 2/13/85, p. 34; Faust 2/19/85, pp. 110, 132-133, 136, 138-139; l Hoyt 2/26/85, pp. 4, 8; ,
Illjes 2/7/85, pp. 11-13, 15-16; '
McGovern 2/6/85, p. 109; Mehler 2/28/85, pp. 57-66; Miller, A. 3/21/85, pp. 20-23; Zewe 2/27/85, pp. 10-11, 37.
8 Congdon 2/13/85, pp. 28, 34, 104.
9 Ibid., pp. 31-33.
10 Ibid., pp. 33-34.
11 _ Ibid., pp. 24-29.
12 Ibid., p. 25.
13 Ibid., p. 25.
14 Ibid., pp. 26-28.
15 Ibid., p. 28.
l 16 Ibid., p. 29.
17 Ibid., p. 29.
1 l
. s JOSEPH R. CONGDON 18 Congdon 2/13/85, pp. 32-33.
19 Ibid., pp. 32-33, 20 Ibid., p. 33.
21 Ibid., p. 34.
22 Ibid., p. 34. .
23 Ibid., p. 34.
24 Ibid., pp. 102-104.
25 Vol. III, Table 2.
26 Congdon 2/13/85, pp. 50-51.
27 Ibid., pp. 50-51.
28 #
Ibid., pp. 39, 86-87.
l 29 Vol. III, Table 2.
30 Congdon 2/13/85, p. 25.
31 Ibid., pp. 31-34, 87.
32 Ibid., pp. 34, 86-87.
l 33 Vol. III, Table 2. .
34 Ibid.; s Vol. IV (MPR Report), Appendix K, Test Numbers 110, 107, 105, 102, 99, 78, 76.
35 Congdon 2/13/85, p. 49.
36 Vol. IV (MPR Report), Appendix K, Test Numbers 109, 103, 96, 79, 69.
37 Congdon 2/13/85, p. 48. ,
38 Vo3 <. IV (MPR Report) , Appendix K, Test Numbers 110, 107, 105, 102, 99, 78, 76, 72.
r i
~
k* .$ ,p
JOSEPH R. CONGDON 39 Vol. IV (MPR Report) , Appendix K, Test Number 78, u 40 Ibid., Test Number 72.
41 Vol. IV (MPR Report) ,Section IV and pp. V.18 - V.22.
42 Congdon 2/13/85, pp.98-101.
43 Vol. III, Table 2.
44 Ibid.
45 Ibid.
46 Ibid. ,.
47 Vol. IV (MPR Report), Appendix K, Test Numbers 38, 32, .
24.
48 Congdon 2/13/85, p. 52. ~
~
49 Ibid., pp. 53-54. -
50 Ibid., p. 55.
51 Ibid., p. 56.
52 Ibid., p. 56.
53 Ibid., pp. 56-57. ;
54 Ibid., pp. 57-58. ,
55 Ibid., p. 58.
56 Ibid., pp. 60-61, 109-110.
57 Ibid., p. 110.
58 Ibid., p. 60.
59 Ibid., pp. 52-53.
/ '
60 I, bid., p. 60.
61 Ibid., p. 53.
P I# 4 \
na
\
JOSEPH R. CONGDON ,
< r, 62 Congdon 2/13/85, p. 54.
63 Ibid., p. 54.
64 Ibid., p. 54.
65 Ibid., p. 55.
66 Ibid., pp. 55, 58-59.
67 Ibid., p. 61.
t 68 Ibid., p. 60.
69 Ibid., p. 60.
70 Ibid., pp. 61-62.
71 Ibid., pp. 109-110.
72 vol. IV (MPR Report), Appendix K, Test Number 38.
73 Ibid., Test Numbers 32 and 24;
Vol. III, Table 2.
74 Ibid., Table 1; . -
Vol. IV (MPR Report),Section VII. .g ;,)
75 Ibid.,Section IV, Figure IV-20. .;
76 Ibid., pp. III.10-III.13.
77 Vol. III, Table 1; Vol. IV (MPR Report) ,Section VII.
78 Congdon 2/13/85, pp. 77-78.
79 Ibid., pp. 80-81. ,
80 Ibid., p. 81.
81 Vol. IV (MPR Report) , Appendix H, Table H-1.
82 Ibid.
B
. .I se t
's I N w r,0 ,
- I
R 4 JOSEPH R. CONGDON 83 Vol. III, Table 1, Table 2.
84 Congdon 2/13/85, p. 108.
85 Ibid., pp. 14, 73.
<36 Ibid., p. 34, 87 Vol. III, Table 2; Vol. IV (MPR Report), Appendix K, Test Numbers 146, 145, 144, 143.
88 Ibid., Test Numbers 146 and 145.
89 Haverkamp 3/3/85, pp. 5, 10.
90 Congdon 2/13/85, p. 69.
91 Ibid., p. 68.
92 Ibid., p. 74.
93 Ibid., pp. 74-75.
l 94 Ibid., p. 69.
95 Ibid., p. 70.
96 Ibid., p. 73.
97 Ibid., p. 73.
" 98 Ibid., p. 74.
99 Ibid., pp. 101-105.
100 Ibid., pp. 101-105.
101 Vol. IV (MPR Report), Figures IV-2, IV-20.
102 vol. III, Table 2; 1 Vol. IV (MPR Report), Appendix K, Test Number 4.
t
[ corrected 1/17/86)
JOSEPH R. CONGDON
\
Vol. III, Table 1, Table 2.
84 Congdon 2/13/85, p. 108.
85 Ibid., pp. 14, 73.
86 Ibid.. p. 34.
87 Vo III, Table 2; Vol.NIV (MPR Report), Appendix K, Test Numbers 146, 145, 344, 143.
88 Ibid., T t Numbers 146 and 145.
89 r,.,erkamp 3 85, p. 10.
90 Congdon .2/13/85 p. 69.
91 Ibid., p. 68.
92 Ibid., p. 74.
93 Ibid., pp. 74-75.
s 94 Ibid., p. 69.
95 Ibid., p. 70.
96 Ibid., p. 73.
97 Ibid., p. 73.
98 Ibid., p. 74.
99 Ibid., pp. 101-105.
100 Ibid., pp. 101-105.
101 Vol. IV (MPR Report), Figures IV-2, IV-20.
102 Vol. III, Table 2; Vol. IV (MPR Report), Appendix K, Test Number 4.
s l
_ - - N
(
l-i CRAIG FAUET began employment with Metropolitan Edison Company on December' 5, 1973. Between March 1978 and March i
1979, he worked as a Control ' Room Operator arsigned to TMI-2.
L i Normally, Edward Frederick was the other Control Room Operator h
assigned on shif t with Faust. They were usually supervised by Shift Foreman, Frederick Scheimann, and Shift Supervisor, i
William Zewe. -
Analysias of employee testimony, Reactor Coolant Inventory .
Balance test (leak rate test) records, and related plant documents, suggests that Faust failed to properly utilize leak rate tests for the purpose of measuring reactor coolant system (RCS) leakage and also failed to take required action in response to indications of excessive leakage in October .1978, and January and March 1979.
l l
l There is not sufficient evidence to support a conclusion ,
i that Faust knowingly added water or hydrogen during leak rate tests in order to manipulate test'results.
l e
O i
._ _m. ._.____.____._______a
CRAIG FAUST These conclusions are based on the following information.
Utilization of Leak Rate Tests to Measure Leakage l There is substantial evidence that Faust failed to properly employ the . leak rate test for. the purpose of measuring RCS
! leakage. l 1
It is apparent from his testimony that he was not seriouely !
l committed to using the test for this purpose. Although he made some effort to defend the utility of the test as a tool for approximating RCS leakage, he reluctantly conceded that- his impression :2 t the time was that the test was not that i I
accurate.1 Moreover, he indicated several times during his testimony that he viewed the test as a device to satisfy Technical Specifications and ' did not really even think about j its accuracy.
]
Dincarding Test Results There is considerable testimony from others that it was j common practice at TMI-2 to discard all test results showing unidentified RCS leakage in excess of 'l.0 gpm. MPR's analysis supports this testimony and suggests that 4 approximately 50 percent of the leak rate test results obtained at TMI-2 were not filed.4 ]
- - . - - - - .-----_----a mJ
(
CRAIG FAUST l
Testing patterns on shifts worked by Faust seem to be consistent with this alleged practice. There are no filed tests showing leakage in excess of 1.0 gpm and there are many l shifts on which no leak rate test result was filed.5 1
TMI-2 records indicate that between March 1978 and March 1979, Faust reported for duty and worked as a Control Room operator on approximately 120 shifts during which leak rate i tests presumably could have been performed.6 Despite this I fact, only 28 leak rate tests were filed on shifts worked by i
Faust. Faust signed as the performer of 11 of these testsr-he was responsible for operating the control roomt panel and j maintaining the Control Room Log during most.of the others .
l
- Thus, L1though there was a policy of attempting to perform a leak rate test at least once per shift, tests were actually i filed on less than one-third of the shifts worked by Faust.
I In an affort to explain the high number of shif ts in which no leak rate tests were filed, Faust and others have stated that they were often too busy to attempt to run leak rate tests on the day shift.9 This explanation is not . completely j supported by test data. While there were only a few tests filed on the day shifts . worked by Faust, he also worked ,
numerous 3pm-11pm and 11pm-7am shifts during which no tests I
___________________-____mm__-__.__m__m __
l l
l l
CRAIG FAUST l
I 10 Thus, the increased administrative burdens of were filed .
the day shift do not fully explain the failure to file tests on
! so many shifts.
i Our analysis did not yield any explanation that tended to rebut the testimony from others that the primary -reason for ;
failing to file test results was that they demonstrated leakage-in excess of 1.0 gpm. A review of one of the operational ;
l I
periods, in - which the fewest test results were filed on shif ts i
worked by Faust, tends to support such~ testimony.
Between February 6 and March 21, 1979, only four tests were j filed during the 22 shifts worked by Faust.1 Our analysis i
! reveals that this was a period in which increased reactor j coolant -drain tank collection would have made it very dif ficult-to obtain a satisfactory leak rate test because of a calculation error in the procedure.1 Faust r6. *a lled that it was becoming increasingly difficult to obtain satisfactory leak rate test results during this period.1 He attributed the j difficulty to the fact that increasing identified leakage was becoming more difficult to isolate, thereby making it harder to quantify unidentified leakage.14 He stated that, as time progressed, it sometimec became necessary to run as many as l
three leak rate tests per shif t before obtaining a satisfactory 1 -
CRAIG FAUST j i
result.10 He also recalled that he worked some shifts durfng which he could not obtain a satis factory teot rest'lt at all.16 I
Faust admitted that he, too, threw away, and otherwise i l
failed to document, nearly half of the test results that he j
(
t 4
obtained.17 He also admitted that it was probable that most I
of the test results he discarded showed leakage in excess of 18 He maintained, however, that he personally only 1.0 gpm.
discarded test resr.lts that he considered to be invalid because of come error that he might have made in performing these tests.19 For example, if he discovered that an inadvertent water addition had been made during a test, he would simply discard the computer printout and run another test. According t c, Faust, he followed this practice with respect to both satisf'actory and unsatisfactory test results.20 He specifically denied that he threw away all unsatisfactory test results without regard for their validity. 1 On the other hand, he conceded that he was not able to recall ever submitting an unsatisfactory leak rete test that was ultimately filed . 2 2' When it was pointed out that plant records suggested that unsatisfactory results were diccarded irrespective of perceived accuracy, Faust explained that it was his practice to turn over e'l unsatisfactory test
l CRAIG FAUST 1
t results that he cculd not easily invalidate to Scheimann, his Shift Foreman, for further evaluation. He believed that t
l Scheimann conducted some evaluation of these test results and eventually threw them away. He further stated, however, t l l
that he did not know what factors were considered by Scheimann
- before his decisions to invalidate and throw away the l unsatisfactory tests submitted by Faust. He could not i recall specific discussions with Scheimann, nor could he remember any case in which Scheimann treated the unsatisfactory i test results as valid and then directed the operators to begin taking the required action. 6 l
Never th eless , he insisted that it was not his shift's practice to throw away all unsat:3 factory test results regardless of their perceived accuracy. Although Scheimann is no longer employed within the GPU Systeu and refused to submit 1
to an i.iterview during this investigation, Faust's contention was supported by Edward Frederick and, to a certain extent, by William Zews.27 Filing Inaccurate Test Results Examination of test results filed during shif ts when Faust was working reveals that their perceived accuracy could not
l l
l CRAIG FAUST i have been a major factor in the decision to file them. Less than one-third of the filed tests should have been accepted as valid. Several of the tests filed while Faust was on shift l l
on contained obviously inaccurate information the computer printout itself.28 Many other tests were performed during 1 i
non-steady state conditions or otherwise contrary to the test. 1 I
procedure. Four of the six satisfactory tests filed on i
l Faust's shifts between December 16,.1978, and January 5, 1979, l 4
were performed with a faulty makeup tank level transmitter which was oscillating widely during this period.30 l
Plant records and testimony indicates that this 1
instrumentation problem was well known among operations personnel, particularly on Faust's shift.
Faust initially testified that he generally compared leak rate test results with other plant instruments in order to verify the results. Faust claimed that he would only submit results to his Shift Foreman if he believed them to be accurate, and never knowingly submitted an inaccurate test result simply because it was satisfactory.32 When confronted with obviously inaccurate test results submitted on his shift, he conceded that they should not have been filed. He retreated from his initial position by asserting that his review process s
1
- . - - - - - -._--.------._ - a
f I CRAIG FAUST l 1
i I
was not for the purpose of determining the accuracy of the j test, but merely for recognizing major changes in plant conditions.33 He admitted that he was not that concerned with verifying the accuracy of the test results, particularly if they were satisfactory.34 When it was pointed out to him that satisfactory test results were submitted on his shift under circumstances where he must have known of their inaccuracy, he further stated that he thought the leak rate ,
l test procedure was written so as to only call for the !
35 verification of test results over 1.0 gym. He also responded at times by stating that he did not know what he was j thinking at the time he reviewed the test results, or that he l l
did not really analyze the results that carefully.36 l i
With respect to those tests performed with the faulty makeup tank level transmitter, Faust conceded he was aware that for some period of time during TMI-2 operation, one of the makeup tank level instruments was fluctuating more than the other. However, he contended that he did not stop to think that this problem might have an effect on the accuracy of leak rate test results. Since the fluctuating instrument was not tagged out of service, he said he would have considered it usable without any concern for its effect on the outcome of a leak rate test. While he seemed to recall that he may have
! 1 1
l CRAIG FAUST-switched instruments for the purpose of getting better readings on the control panel, he did not believe that he ever switched instruments to get better leak rate test results.40
\
i Among the several tests which were run on Faust's shift l
)
using the inaccurate makeup level transmitter, we found no l
pattern of switching instruments before a leak rate test. On l the contrary, during most of the relevant periods, it seems l l
that Faust's shift made no attempt at all'to switch instruments ,
one way or another during the course of a leak rate test.41 I l l l
Despite the evidence to _ the contrary, Faust continued to insist that he never knowingly submftted invalid test results l simply because they were less than 1.0 gpm.42 ;
i Manipulation of Test Results_
Our investigation did not produce suf ficient evidence to support a conclusion that Faust was involved in the intentional-manipulation of leak ratu test results.
The NRC has not identified any suspected hydrogen additions during leak rate tests that were perfors.ed while Faust was on
l l
CRAIG FAUST l
duty.43 We were similarly unable to identify any evidence of i
l hydrogen additions during these tests.44
[
Faust testified that he was once told by a Control Room l
l Cperator assigned to another shift that leak rate test results might be enhanced by the addition of hydrogen to the makeup tank during the test. According to Faust, however, he did f i
l not believe that this was possible and does not recall ever 1 l
attempting to produce such an effect.46 l
l There is no testimony from anyone else that connects Faust with the manipulation of test results by means of hydrogen additions.
The NRC alleged that improper water additions were made during four of the leak rate tests that were filed while Faust's shift was on duty.47 Our own analysis, however, failed to disclose a pattern of water additions that would support a conclusion that Faust was involved in this type of test manipulation.
An alleged unlogged water addition during the test that was performed at 15:04 on October 14, 1978, could not be confirmed because a power level change tha t took place during the middle
l CRAIC F". DST l
l of the test obscured the makeup tank level trace on the strip chart.4 The makeup level perturbation caused by this power level change looked quite similar to a water addition.
Our strip chart analysis also raised questions regarding l the allegation that a water addition was made during the test of December 24, 1978. The water addition cf December 24, 1978, cppears to have been actually made just before the test and 49 then inaccuratcly recorded in the Contro3 Room 1o9 An unlogged water addition allegedly made dt: ring the test of February 7, 1979, could not be confirmed by us because of a makeup tank level perturbation reflected on the strip O
chart. However, we were able to confirm an allage" unlogged water addition made during a test that was performed cn October 15, 1978, while Frederick and Faust were working. 1 Both of these alleged water additions appear to be part of a " feed and bleed" operation. Also, these tests were both performed and signed during shift turnovers and, therefore, involved other operators.
In addition to those leak rate tests that the liRC found suspicious, we identified six others that Faust was involved in which required fur'cher analysis. Between February 14 and March
l CRAIG FAUST l i' I
l l l 28, 1979, logged water additions were made during each of six l
leak rate tests performed on the shifts that Faust was l working." In each case, because of the combined effects of I
a calculation error in the test procedure and Inlfunctioning makeup tank level instrumentation, the wa t e.:r additions caused 1
test results for unidentified leakage to be significantly l
reduced.54 l l
When Faust was questioned about these water additions, he ,
l I stated that he did not intentionally add water to the makeup j tank during leak rate tests to enhance the test results.55 Moreover, he testified that he was not even aware at that time
! that properly accounted-for water additions would cause such a 4
result.'6 Eowever, he admitted that he was aware of the procedural requirement to avoid water additions during leak rate tests. Accordingly, he stated he would generally add water only when it was deemed necessary to maintain proper makeup tank level or control rod positions.57 When confronted with individual tests involving water additions, Faust was not able to specifically recall why the 8
additions were made during the tests. Howe >.c , he noted that as March 1979 approached, it became necessary to add water very frequently and it was becoming more f fi cult to avoid additions during a tests.
l CRAIG FAUST Faust's testimony is supported by our analysis of the leak 4
rate tests involving water additions on his shift. i Five of the six additions took place during the last half 3
of March 1979 when plant records reveal that water was being added to the makeup tank several times per shift to compensate for increasing reactor coolant drain tank collection.60 Four I of the six additions apparently were necessary to maintain what was generally accepted L _, proper makeup tank level.01 While 1
it is not clear why the remaining two water additions were l l
made, there is no evidence to suggest that they were made in an I effort to falsify leak rate test results.
l l
l Operator Response to Indications of Excessive Leakage The practice of discarding unsatisfactory test results without documentation has made it difficult to identify everv brief period when there were indications that unidentified 1 .
lehkage exceeded 1.0 gpm at TMI-2. However, we were able to identify. and examine closely three such periods . It is clear i that Faust was working at times during these periods when there were indications that unidentified leakage exceeded 1.0 gpm and the required action was not taken.62 The events of these l
i CRAIG FAUST I
periods are fully discussed in Volume I of this report. For i
purposes of this section, these periods are discussed only to the extent that they relate to the action taken by Faust in response to the indications of excessive leakage.
I I
l Faust stated that he was aware in 1978 that if unidentified l l
leakage exceeded 1.0 gpm for several hours, he was required to !
I reduce the leakage to within limits or begin shutting down the plant.63 However, he further stated that if he obtained a l leak rate test result in excess of 1.0 gpm, he would attempt to ensure that it was valid by reviewing other plant instruments before embarking upon the required action.04 He also stated that if he could not determine the test to be invalid, he would i
then turn it over to his Chift Foreman who would actually be l responsible for niaking the decision regarding what course of action was to be taken. According to Faust, he turned over j numerous tests showing leakage in excess of 1.0 gpm to his Shift Foreman; but he was never directed to enter into t.h e action statement.66 He stated that although he could not recall any specific occasions, Scheimann must have thrown these tests away.67 When cpes tioued regarding his response to Scheimann's conduct, Faust said that while he might have expressed j
i
.I i
I CRAIG FAUST I
]
. l l frustration over having to perform anoth er leak rate test, he i
j did not remember whether he ever disagreed with Scheimann l
l regarding his decision not to take required action.68 He said that he could not remember any discussions with Scheimann regarding the appropriate response to tests showing excessive 1
l leakage.69 Faust said that all he can definitely remember j l
thinking was that sooner or later they would not be able to get I satisfactory test resu]ts and that they would eventually have 0
to shut down the plard. 1 l
October 16 - 22, 19 3 j Subsequent to obtaining a successful leak rate test at l
l 19:28 on October 15, 1978, Operations personnel apparently began to experience RCS leakage problems and difficulty in obtaining satisfactory leak rate tests. No tests were filed I
during the first two shifts on October 16, 1973. Faust, Frederick and Scheimann reported for duty at 15t00 on October 16.72 At 20:35 a leak rate test was performed which showed 3
unidentified leakage at 2.56 gpm. However, this test, was not signed.
1 l
i on October 17, other Operations personnel were attempting to identify the source of RCS leakage and had obtained another unsatisfactory leak rate test (2.07 gpr;) before Faust's shift reported for duty.74
- 15 _
L i
I a
CRAIG FAUST l >1
! i l
At 15:00 on October 17, Faust, Frederick, Scheimann, and l l
.Zewe again reported for duty. Despite the unsatisfactory test
(
results thrt had been previously obtained, they did not . enter i i
"the action statement and proceed to shut the plant down. '.l According to the plant records, they continued to search for i
-leakage and operate the. plant. They did not file.a leak ' rate l
.1 tet: t result for that shift.'5 i
(
1 i
After reviewing various plant records, Faust confirred that i on October 16, 1978, he was operating the control panel and.
6 Frederick was responsible for surveillance. He was not-I able to explain, based or, the records, why they did not enter' ~J the action statement on October 16 or 17.77 In his opinion, it was management's responsibility to make that kind of decision.78 He did point out, however, that. the plant -l records indicated they were attempting to do something about the leakage.79 l
( Similarly, neither Frederick nor Zewe had any explanation l l i l
or recollection why the action statement was not entered at that time.
L l
l i
- 3 f
t CRAIG FAUST l
-Dacember 26, 1978 - January 15, 1979 j l
Our analysis reveals that unidentified leakage gradually increased to above 1.0 gpm on about January 3, 1979, and j remained at that level until January 15, 1979, when the plant was shut down.
j
(
f Faust and Frederick turned in satisfactory leak rate test f results on January 4 and 5, 1979; both were obtained with the j l
use of the faulty makeup tank level transmitter.81 >
-i Thereafter, they worked five consecutive assigned shifts during j which no leak rate test was filed. There are indications that Faust and his colleagues were aware that RCS leakage was l on the increase, particularly by January 11, when Hoyt entered {
l the D-ring and attempted to estimate RCS leakage from the f pressurizer valves during Faust's shift. Given the evidence regarding the practice of discarding unsatisfactory test results, it is likely that unsatisfactory results obtained {;
during this period were discarded without documentatiet,. l It is clear that Faust, and other personnel assigned to the TMI-2 control room during this period, did not take actior to shut the plant down despite the information that was available ,
i to them. .
I g
i
i i
l l
CRAIG FA'UST !
1 Faust testified that he did recall going through more than I
one shift without being able to get a good leak rate test, but l he could not remember the specifics.84 He further stated I
that had he obtained unsatisfactory test results during this j 3
period that he could not invalidate, he would have turned them l 1
over to his Shift Foreman for appropriate ac' tion. Although he stated that this probably occurred, he could not remember any particular incident.86 Similarly, Frederick and Zewe testified that they could not remember the specific events of this period.87 i
! March 15 - 28, 1979 Our analysis indicates that unidentified leakage increased during March 1979, until it came close to 1.0 gpm on March 15, and remained fairly constant thereafter. However, for the reasons described in Volume I, operators woulf have perceived unidentified leakage to be much greater.
Faust turned in a negative leak rate test result on March 16, and then worked five consecutive assigned shifts during which no leak rate was filed,bb Satisfactory leak rate tests were then filed on his shifts on March 24, 25, 27 and 28. Each
L ]
l 1
I 1
CRAIG~ FAUST l 4
1 of these yielded satisfactory results because water additions during the test caused unidentified leakage te be reduced for reasons previously explained.89 I
l Given the testimony and the available plant documentation, ;
it is highly probable that unsatisfactory test results obtained by Faust and Frederick during 'this period were discarded and not otherwise docuni;nted.
I i
There does not appear to have been any information- 4 available at that time that would have justified -either the
- discarding of unsatisfactory results or the failne to take )
l required action in response to such results. This- is
]
particularly true since during this period the operators were
,l manually recalculating the test results. generated by the computer to correct for a calculation error in . the computer program. Therefore, the operators should have perceived the recalculated results for unidentified leakage to' be more accurate and reliable.
i i
l 1
CRAIG FAUST 1 Faust 2/19/85, pp. 12-15, 50-52.
l 2 Ibid., 2/19/85, pp. 12-13, 16, 56-57, 59-60, 186; 2/20/85, pp. 12-13, 23.
3 Adams 3/19/85, p. 13; Coleman 2/5/85, pp. 32-33; ,
Congdon 2/13/85, 34; J Faust 2/19/85, pp. 110, 132-133, 136, 138-139; 1 Hoyt ?/26/85, pp. 4, 8; i Illjes 2/7/85, pp. 11-13, 15-16; )
McGovern 2/6/85, p. 109; Mehler 2/28/85, pp. 57-60, 63-64, 66; A. Miller 3/21/85, pp. 20-23; i Zewe 2/27/85, pp. 10-11, 37. l I
4 Vol. IV (MPR Report), pp. V.2-V.9, Figures V-1 V-4. )
5 Vol. III, Table 2, 6 Ibid.
7 Ibid.
i 8 Ibid.
9 Faust 2/19/85, p. 62.
10 Vol III, Table 2.
11 Ibid.
12 voi, yy (gpR Report),Section IV. )
I 13 Faust 2/19/85, P. 62.
14 Ibid., p. 61.
15 Ibid., pp. 41-42, 53.
16 Ibid _., pp. 53, 135.
17 Ibid., pp. 55-56, 136.
18 Ibid., p. 136.
19 Faust 2/19/85, pp. 90, 101-102.
t CRAIG FAUST ,
i 20 Ibid., pp. 98, 101. l 21 Faust 2/19/85, p. 95; 2/20/85, p. 59.
22 Faust 2/19/85, pp. 55, 110, 23 Faust 2/20/85, pp. 42-43.
24 Faust 2/19/85, pp. 105-106, 108; 2/20/85, p. 94.
25 Faust 2/19/85, pp. 120-126; 2/20/85, p. 59. l 26 Faust 2/19/85, pp. 105-107.
27 Frederick 3/12/85, p. 85; Zewe 2/27/85, pp. 11, 40-46.
28 Vol. III, Table 2.
29 Ibid.
30 Vol. IV (MPR Report), Appendix K Test Numbers 94, 75, 74, 73 l
31 Vol III, Table 4; Zewe 2/27/85, pp. 28-29, 95; Frederick 3/14/85, pp. 71, 105; g McGovern 2/6/85, pp. 37-39, 96, 89. I 32 Faust 2/19/85, p. 101.
33 Faust 2/19/85, pp. 139-140, 183-184; 2/20/85, pp. 23-24.
l 34 Faust 2/20/85, pp. 34-35, 50-52, 75-79.
l 35 Faust 2/19/85, p. 115.
36 Faust 2/20/85, pp. 53, 75-77 37 Faust 2/19/95, pp. 16-18; 2/20/85, pp. 5-6.
38 Faust 2/19/85, pp. 17-18.
l [ corrected 1/17/86] -
_ _ _ _ _ _ _ . _ _ _ _ _ k
l CRAIG FAUST
! l i
l 20 Ibid., pp. 98, 101.
l l 21 Faust 2/19/85, p. 95; 2/20/85, p. 59. I 22 Fa et 2/19/85, pp. 55, 110. ,
l 23 Faust 2/20/85, pp. 42-43. l l
24 Faust 2 9/85, pp. 105-106, 108; j 2/ /85, p. 94.
l l l
25 Faust 2/19 5 120-126; l 2/10/8h, s, pp.p. 59. l l
26 Faust 2/19/85, p. 105-107.
l 27 Frederick 3/12/85, p. 85; l Zewe 2/27/85, p. 11, 40-46. l 28 Vol. III, Table 2. l 1
29 Ibid.
30 Vol. IV (MPR Report), Appe dix K Test Numbers 94, 75, 74, 73 31 Vol III, Table 4; Zewe 2/27/85, pp. 28-29, 95, Frederick 3/14/85, pp. 71, 105; McGovern 2/19/85, pp. 37-39, 96, 8 .
32 Faust 2/19/85, p. 101.
33 Faust 2/19/85, pp. 139-140, 183-184; 2/20/85, pp. 23-24.
34 Faust 2/20/85, pp. 34-35, 50-52, 75-79. \
35 Faust 2/19/85, p. 11r.
36 Faust 2/20/85, pp. 53, 75-77.
- 37 Faust 2/19/85, pp. 16-18; 2/20/85, pp. 5-6.
38 Faust 2/19/85, pp. 17-18, 1
~
- 21 -
t______________.____
CRAIG FAUST 39 Faust 2/19/85, pp. 19, 34-40, 184; l 2/20/85, p. 21.
40 Faust 2/19/85, p. 36; 1 2/20/85, p. 21.
41 Vol. III, Tables 1 and 2; Vol. IV (MPR Report), Figure V-5. l 42 Faust 2/19/85, p. 101.
43 Vol. III, Table 2.
44 Ibid.
45 Faust 2/19/85, pp. 20-25.
1 46 Ibid., pp. 20-25, 47 Vol. IV (MPR Report), Appendix K, Test Numbers 152, l 150, 84, 50.
48 Ibid., Test Number 152.
49 Ibid., Test Number 84.
50 Ibid., Test Number 50.
51 Ibid., Test Number 150.
52 Vol. III, Table 1.
53 voi, Iy (gpR Report) Appendix K, Test Numbers 40, 9, 4, 3, 2, 1.
54 ~
Ibid.,Section VI.
55 Faust 2/20/85, p. 79.
l 56 Faust 2/19/85, pp. 83-84; 2/20/85, pp. 65-66.
57 Faust 2/19/85, pp. 77-79.
l 58 Faust 2/20/85, p. 66.
l 59 Faust 2/19/85, p. 75; 2/20/85, pp. 77-79.
4*
3
- . *M
%, & IMAGE EVALUATION
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////f .
CRAIG FAUST 60 Vol. IV (MPR Report), Appendix K, Test Numbers 9, 4, 3, 2, 1.
61 Ibid..
62 Ibid., Figure IV-20; Vol. III, Table 2.
63 Faust 2/19/85, p. 46.
64 Ibid., pp. 46-48, 57-58, 118-120.
65 Faust 2/19/85, pp. 49, 107-109, 117-118, 165; 2/20/85, p. 40.
66 Ibid., pp. 51-52, 94-97, 102.
67 Faust 2/19/85, pp. 116-117, 120, 121-122; 2/20/85, pp. 39, 102, 68 Faust 2/19/85, pp. 116-117; 2/20/85, pp. 42, 44, 60-61, 103-104.
6@ Faust 2/19/85, pp. 119, 120-121; 2/20/85, p. 104.
70 Ibid., pp. 52-53, 61, 103.
71 Vol. III, Table 1.
73 Ibid., Table 2.
73 Vol. IV (MPR Report), Appendix K Test Number 149.
74 Vol. III, Tables 1 and 4; Vol. IV (MPR Report), Appendix K, Test Number 148.
75 Vol. III, Tables 2-4.
76 Faust 2/19/85, pp. 159-160.
77 Ibid., pp. 163-164, 166.
78 Ibid., pp. 164-165.
79 Faust 2/19/85, pp. 165, 166.
80 Frederick 3/12/85, pp. 124-125, 130; Zewe 2/27/85, pp. 70-71.
l-CRAIG FAUST 81 vol, Iy (MpR Report), Appendix K, Test Numbers 74, 73.
82 Vol. III, Table 2.
83 Ibid., Table 4.
84 Faust 2/20/85, pp. 37-40.
85 Ibid., p. 40.
86 Ibid., p. 41.
IB7 Frederick 3/14/85, pp. 51, 55-56, 71-73, 80, 86; Zewe 2/27/85, pp. 103, 104, 106, 110-111, 114-115.
88 vol, III, Table 2; Vol. IV (MPR Report), Appendix K, Test Numbers 4, 3, 2, 1.
89 Vol III, Table 2.
I 1
l I
l '
l i
____________C
I I
1 began as an engineer WILLIAM FELS employment with Metropolitan Edison Company on January 8, -1976. He is presently employed by GPU Nuclear Corp. as an Engineer Senior I at i'MI-1. Between March 1978 and March 19'/9, Fels was assigned as an engineer to start up and check the rMI-2 computer i systems. Although his duties indirectly exposed him to leak rate testing, we did not uncover any evidence that he was involved in any improper conduct while he was employed in that capacity.
Fels testified that he was the individual who installed the computerized leak rate test program at TMI-2. He indicated that it was a relatively straightforward assignment that he was able to complete without any real supervision.1 Essentially, Fels stated that he adapted the TMI-l leak rate test program for use in the TMI-2 computer.2 The only differences between j the TMI-1 and TMI-2 computer programs that Fels could recall were the lack of an evaporative loss factor in the TMI-2 procedure and the fact that values for various plant parameters were stored in different memory locations in the two units.3 l
__________---a
l 1
i WILLIAM FELS J
\
J Fels pointed out that he was not involved in the development of the leak rate surveillance computer program at
)
l TMI-1, nor was he responsible for the development of the leak j rate test procedure at TMI-2.4 He further stated that at the l l
time he installed the procram at TMI-2, he did not question its !
adequacy since he was not responsible for making those kinds of l
decisions.5 Fels also stated that, at the time of the !
installation, he was not aware of any calculation errors in the TMI-2 procedure, but conceded that if there were errors, he would have simply carried them over into the TMI-2 computer program.0 He explained that he was not really aware of what kind of test results were being generated since it was not his responsibility to keep track of the numbers.
l For the most part, Fels testified that he did not recall being aware of major problems with the computer program for leak rate testino in 1978-1979.8 He did have some vague
! recollection that getting negative leak rate test results had been a problem at one time but, beyond that, he could not l
recall specifics.9 He also recalled that he had received i i
complaints from Operations Department employees that the leak l
rate test results that they were getting were not consistent with indications of leakage from other sources in the plant.10 l
l i
I 1
)
WILLIAM FELS 4 The evidence that we reviewed supports Fels' testimony and does not suggest that he performed his duties in a way that facilitated improper leak rate testing practices. While there were undoubtedly errors in the computer program for leak rate I testing, the testimony, computer log, and other plant documents suggest that Fels made a good faith effort to correct the problems when they were discovered.11 I
i The only conduct of Fels that we know of that gives rise to questions regarding his involvement in improper leak rate testing stems from the fact that he was the person who programmed the computer to print out only whole numbers for identified reactor coolant system leakage after the October 18th NRC inspection. According to Fels, he could not clearly recall the circumstances under which he came to make the round-off modification. He stated that as far as he could remember, James Floyd, or Shift Supervisors, probably l instructed him to make the change to the computer program. Me
! could not be certain, but he believed that Floyd explained the !
justification for the modification to him at that time and led him to believe that it had been approved by management and the NRC.12 He was certain that he would not have made such a modification without these kinds of assurances.13 s
i l
_.______________a
WILLIAM FELS In any event, Fels testified that he modified the procram to print out only whole numbers and recorded the modification in the computer 104.14 He also remembered that only a short i
time later, a Shift Supervisor called him and told him that Herbein wanted the round-off modification to be deleted immediately.15 Fels stated that he did not remember with certainty which supervisor called him, but he thought that it was Bernard Smith.16 Smith testified that he did not remember such a conversation.17 Nevertheless, it is clear that Fels did make the program changes in question and it is quite likely that he was followino instructions from Operations Department management.
There is no reason to believe that he was actino on his own initiative or with any improper motive at the time.
Since Fels admitted that he spent considerable time in the control room, we questioned him about his knowledge of improper leak rdte testing practices on the part of Control Room Operators.
Fels stated that he never personally ran a leak rate test himself, except for experimental purposes.
Moreover, he did not have any responsibility for the oversight of leak rate testing. He acknowledged that he often had contact with Operations Department employees, but stated that he never witnessed any improper conduct on their part.
WILLIAM FELS Specifically, he testified that he never observed anyone add water or hydrogen to the makeup tank to manipulate a test result and that he had no reason to believe that anyone was engaged in that kind of conduct.19 There was only one test that Fels apparently had some involvement with that was of a suspicious nature. That test was run on October 18, 1978, at 12:21 pm by Olson and Adams.20 It was apparently the same test that was shown to Haverkamp during his October 18th inspection in order to demonstrate to him that the leakage problem that had existed had been resolved. The test printout bears a handwritten notation that the test was " corrected by Bill Fels." The NRC has alleged there were unrecorded water additions durino this test, but MPR was unable to confirm these additions because of the ambiguous makeup tank level traces found on the strip chart for that day. Fels testified that he could not recall this particular test, but it seems f.om the markings on the printout that his role was limited to making a manual correction to the test printout after the result was obtained. We found nothing to suggest that he would have' been aware of any unrecorded water addition, even if one had taken place.
-S-
WILLIAM FELS Fels also testified that he was not aware that TMI-2 operators were discarding unsatisfactory test results. He conceded that he was often at the computer when tests were !
)
performed, but he stated that he never saw anyone throw away a l
test result. However, he did remember operators walking away j i
from the computer toward the supervisor's office with the .)
printout and that they stars.ed tests over.22 He maint11.ed, however, that he didn't witners any tests being discarded.23 Finally, Fels testified that he was not aware of any problems with excessive reactor coolant system leakage at TMI-2
! and did not recall ever overhearing discussions about shutting l
down the plant or entering the action statement because of reactor coolant system leakage.24 We found no evidence to l l suggest that he did.
1
'I ,
WILLIAM. FELS' -
l' Fels 3/26/84, p. 13. ;
- 1 3 ' Ibid., p. 7. l
'l 3 Ibid., pp. 11-12.
4 Ibid.,.p. 7.
5 Fels 2/25/85, p. 6.
6 Ibid., p. 16. j 7 Fels 3/26/84, p.-8.
i 8 Ibid., p. 14.
'l 9 Fels 2/25/85, p. 14.
']
10 ' Fels 3/26/84, p. 18, 11 "
Fels 3/26/84, p. 8; ;
2/25/85, pp. 24-26. !
12 Fels 2/25/85, pp. 36-38.
13 Ibid., p. 38.
14 Ibid., pp. 35-36.
l 15 Ibid., p. 39.
I 16 Ibid., p. 39, i
17 Smith 2/8/85, p. 102. l 18 Fels 3/26/84, p. 13.
1 19 Ibid., pp. 23-24.
l 20 Vol. IV (MPR Report) , Appendix K, Test Number 143.
21 Fels 2/25/85, p. 33.
'22 Ibid., p. 13.
23 Ibid., p. 13.
l 24 Fels 3/26/84,-pp. 21-22.
k l
E l
1 1
1 EDWARD FREDERICK began employment with Metropolitan Edison Company on November 28, 1973. Between March 1978 and 1
March 1979 he worked as a Control Room Operator assigned to TMI-2. Normally, Craig Faust was the oth er Control Room
]
Operator assigned on shift with Frederick. They were usually supervised by Shift Foreman, Frederick Scheimann, and' Shift Supervisor, William Zewe. l Analysis of employee testimony, Reactor Coolant Inventory Balance (leak rate) test records, and related plant documents, suggests that Frederick failed to properly utilize leak rate tests for the purpose of measuring reactor coolant system (RCS) 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.
l There de not sufficient evidence to support a conclusion that Frederick knowingly added water or hydrogen during leak rate tests to manipulate test results.
m i
EDWARD FREDERICK These conclusions are based on the following information.
Utilization of Leak Rate Tests to Measure Leakage Discarding Test Results There is substantial evidence found in TMI-2 records that suggests that Frederick failed to properly employ the leak rate test for the purpose of measuring RCS leakage.
Between March 1978 and March 1979, Frederick reported for duty and worked as a Control Room Operator on approximately 114 shifts during which leak rate tests presumably could have been performed.1 Despite this fact, only 25 leak rate tests were filed on shifts in which Frederick was working.2 Frederick signed as the performer of 14 and was responsible for operating the control room panel and maintaining the Control Room Log during most of the others. He was also responsible for doing surveillences when the unsigned leak rate test of October 16, 1978, was performed, but he has testified that he does not recall whether he performed this test.4 Thus, despite a company policy of attempting to perform a leak rate test at least once per shift, tests were actually
EDWARD FREDERICK filed on approximately one-quarter of the shifts that Frederick was- working.5 Frederick, unlike most of his colleagu,es,
! claims that the company policy 6t . the time wes to perform a j leak rate test only once per day on the 11pm-7am shift unless !
specifically ordered to do otherwise.6 Test records from his l l
shift, howeve r ,' are not consistent with his testimony. Of the l
25 leak rate tests that were - performed while Frederick was on shift, five were run on the 7am-3pm shift, five were run on the 3pm-11pm shift and 15 were run on the llpm-7am shift.
Moreover, there were at least 20 11pm-7am shifts that Frederick
! worked where no leak rate test was filed at all.
l 1
There are also several instances of consecutive assigned ;
1 shifts when Frederick was working that no leak rate tests were filed. These gaps in filed tests appear from March 1978 right up through the accident.9 l
Aside from the fact that no tests were filed showing leakage in excess of 1.0 gpm, there are no obvious patterns +
associated with leak rate testing done on Frederick's shifts.
e There is one period when his shift regularly filed test results between December 23, 1978, and February 11, 1979.
EDWARD FREDERICK During that time, 10 tests were filed on 19 shifts; but, motst of these tests were improperly performed, as will be discussed -
later.11 1
. . 1 l On the other hand, from February 12 to March 21, 1979,'only 1 l
two tests were filed out of the eighteen shifts that Frederick worked.12 I
l l Our analysis reveals that this was a period in which there was increasing reactor coolant drain tank collection that would j have made it very difficult to obtain a' satisfactory lebk rate test because of the calculation error in their leak rate test j procedure. Craig Faust, in his testimony concerning this period, recalls that it was becoming increasingly dif ficult to obtain satisfactory leak rate test results.13 Faust stated l l that as time progressed, it became necessary to run.up to three. I leak rate tests per shift before a satisfactory result could be obtained.14 Frederick states that he' recalls. no such I
difficulty in obtaining satisfactory leak rate test results during any period of operation at TMI-2.15 There is, of course, considerable testimony from others that it was common practice at TMI-2 to discard all test results showing unidentified RCS leakage in excess of 1.0 i
i t
a
EDWARD FREDERICK 16 this testimony and suggests gpm. MPR's' analysis supports j that approximately 50 percent of the leak rate test results cbtained at TMI-2 were not filed.1 t
The absence of filed tests on so many of Frederick's shifts l
supports this conclusion. Nevertheless, Frederick's testimony l
-1 on this issue is at variance with the test records and with the j testimony of most of the TMI-2 operators as well.
Frederick testified that he used the leak rate test as his O
primary method for measuring RCS leakage. He believed that there was no other leakage monitoring system in place that 9 result, could accurately measure RCS leakage. As a Frederick stated that he would take precautions to ensure that proper plant conditions existed at the start of his tests and I
l would always carefully examine the results at the end of the test.20 By following this approach, he believed that nearly all of the test results that he obtained were accurate.21 He does not recall that test results were high2y variable or that it was often necessary to repeat tests to obtain a l
satisfactory result.22 He stated that he did not really know why other operators experienced difficulty in obtaining accurate results, but speculated that perhaps he was more
EDWARD FREDERICK careful in obtaining suitable plant conditions before running a l
l test.23 In any event, upon the completion of tests and his own review of the results, Frederick said he would invariably turn over the test records to Scheimann, his Shift Foreman.'24 Unlike ' other Control Room Operators, Frederick and Faust did not enter test results in the Control Room Log.25 1
1 According to Frederick, he does not remember ever i personally discarding a leak rate test result, nor does he recall that Faust or Scheimann.ever discarded a test result in his presence. 26 He stated that he believed that Scheimann should have filed all test results and he assumed that he was l 27 He further stated that he now thinks it possible doing so.
that Scheimann may have discarded tests only because he remembers having submitted at least some inaccurate tests that .l have not turned up in- Company records.28 He pointed out, however, that it is also possible that the GMS coordinator may have thrown them away.29 It should be noted that Faust has testified that he threw away as many as half the results that he obtained.30 When Frederick was asked whether he ordinarily discussed these allegedly inaccurate tests with Faust, he indicated that he was EDWARD FREDERICK a " sharp operator" who was able to understand the audible and visual signals available in the control room and interpret them without having to consult with Faust.
l l With respect to the inaccurate tests that he submitted, Frederick stated that he did not recall ever filing an i i
Exception and Deficiency.
l He indicated that he understood when an Exception or l
Deficiency was required and must have felt that none was necessary in connection with the tests that he submitted.33 j In this regard, Frederick initially testified that he believed that all the indicated test results he submitted to Scheimann showed leakage less than 1.0 gpm.34 When pressed ' further on this point, he conceded that this was unlikely and then indicated that he did not recall specifically whether the results were greater or less than 1.0 gpm.35 l In any event, he maintained his position that all tests that he performed were submit ted to his Shift Foreman and that the test printouts would be the only documentation of this fact.36 He further stated that, if no test were on file for any shift that he worked, it would be because no test was performed or that the test printout was disposed of without his
EDWARD FREDERICK involvement after he submitted it to Scheimann. Scheimann is no longer employed by GPU and declined to be interviewed I during our investigation.
Filing Inaccurate Test Results i
Frederick testified that he believed that leak rate test l l
results submitted by him were generally accurate. He stated that he was ab3e to achieve nearly all accurate test results by carefully choosing test conditions beforehand and by carefully examining test results when they came out.38 It was his opinion that no other leakage monitoring system was available 1
at TMI-2 that was useful for verifying the accuracy of test ;
results. Consequently, he would attempt to verify test results by visually scanning the same plant instruments that the computer read both before and during the tect to ensure that j nothing was occurring to disturb the accuracy of the test.39 In fact, he claimed that he could visually scan the control room instruments and mentally do a leak rate test that was as reliable and accurate as the computer run test.40 If he determined that plant conditions were riat stable at any time before or during a test, he would avoid running the test or suspend the test if it had already been started.41 A leak rate test performed by him on January 4, 1979, demonstrated
EDWARD FREDERICK that he did in fact know how to interrupt a computerized test and start it over again minutes later.42 According to Frederick, he was able to generally obtain accurate results by following this procedure. On those occasions when he somehow obtained what he believed to be an inaccurate result, he would nevertheless sign the test, turn it in to his Shift Foreman, and advise the Shift Foreman that he believed the test was inaccurate.
An examination of the tests submitted during shifts that Frederick was working disclosed that test results were not nearly as accurate as he seems to recall. Nearly one-third of the 31 tests yielded results that should have been considered -
invalid. #s Of the 14 tests that were actually signed by Freder".ek , 6 of them contained errors or were not correctly performed 3 45 The leak rate test that he submitted on May 28, 1978, was run on the computer when the plant was in cold shutdown and the temperature therefore was printed out in dollar signs.46 The leak rate test procedure makes it clear that the computer was not to be used for a leak rate test when RCS temperature was below 525*.47
i EDWARD FREDERICK l
The test of October 14, 1978, was performed during a reactor'startup and the test of December 31, 1978, contained an improperly entered value for identified leakage.48 Tests for l
' December 23, 1978, January 2, 1979, and January 4, 1979, were performed with the faulty makeup tank level transmitter.49 The test of February 7, 1979, was actually performed on the previous shift and Frederick signed this test despite the fact
'that he apparently was not present when the test was run.50 When discussing his general procedures, he testified that he would not sign a test that someone else had run unless he had 1 verified its accuracy.51 l
For the most part, when Frederick was confronted with these l tests, he either refused to concede that they were inaccurate or took the position that he could not make any determination regarding their accuracy because there was insufficient information at hand.52
! )
one example of his testimony in this regard involves his use of the faulty makeup tank level instrumentation during leak l rate tests of December 23 and December 30, 1978, January 2 and January 4, 1979.53 I
! l t
1 1
l 4
EDWARD FREDERICK .
l 1
l During the earlier portion of his interview, Frederick l
l testified that it was his practice to routinely check makeup tank level before running a leak rate test.54 He did not j recall any period when one of the makeup tank level instruments j i
was not working properly.55 He said, however, that, had he !
known of such a problem at that time, he would have used the instrument that was working properly for the leak rate test; j and he would have submitted a work request to have the faulty one corrected.56 i
He later stated that an operator could not tell which instrument was more accurate unless there were already an j l out-of-service sticker on one of them.57 He added, however, ;
! j that if an instrument jumped more than one percent, it was out of calibration and if it was suspected of being erratic after a channel check, it should be declared out-of-service.58 l He went on to state that if he found that two makeup tank j level instruments did not agree with one another, he did not l
think he would have run a leak rate test.59 I i
o t
Upon being shown the leak rate test of December 16, 1978, that was run by Hugh McGovern (Frederick was on shift) with the bad transmitter, Frederick did not remember saying it would l 1
i E______----____________--___------___--- }
EDWARD FREDERICK have been his practice not to run a leak rate test if he thought one of the instruments was inaccurate. Since he could not remember such a problem, he could not really tell whether he would have run a leak rate test at that time.61 ;
When Frederick was confronted with the test result of I Eecember 23, 1978, he began by pointing out that he did not I think that he did a channel check on every shift.62 He also remarked that, in any event, a channel check by _ itself might I
not tell an operator if the signal he was getting was occurate. He further stated that he could not really tell without further information which makeup level instrument was accurate at that time. Ultimately he indicated-that he did not remember ever being confronted with a situation in which the two instruments did not agree, but given that information today, he did not think he would run a test.63 Finally, Frederick was questioned about the tests of December 31, 1978, and January 2 and 4, 1979.64 Despite substantial evidence that he was probably aware that one of the level transmitters was not working properly at that time and that the tests were performed with the faulty transmitter, he refused to concede that the test results were invalid. He also denied that he ever knowingly ran a test with the faulty b_______________-______
(
EDWARD FREDERICK ,
i level transmitter. He concluded by saying that if he did run such a test, it must h,2 ve been because he was either unaware j that the instrument was out-of-service or for some other reason ;
that he cannot explain without additional information.66 Given his testimony regarding the careful manner in which he performed leak rate tests, it is hard to understand how he -
might have inadvertently submitted so many inaccurate test results. In any event, it is clear that Frederick did not properly utilize leak rate tests to measure RCS leakage during most of'the shifts that he worked.
Manipulation of Test Results I i
l l
The NRC has identified only one suspected hydrogen addition during a leak rate test that was run by Frederick or while Frederick was assigned to the control room panel on December 30, 1978.67 Our analysis revealed that the test in question was performed with faulty makeup tank level instrumentation 1 that produced a widely fluctuating strip chart level trace.
Because of the characteristics of the trace and the fact that !
lI the alleged aidition was not log;ged, it is not possible to confirm the addftL.n.
i l
l l l I
l I
I l
EDWARD FREDERICK Frederick has denied that he ever added hydrogen to the makeup tank to enhance a leak rate test result. According to him, he was not even aware, prior to the accident, that hydrogen additions could cause an indicated makeup tank level change.68 i l l
Faust has also testified that he did not believe that this was possible and that he never attempted to produce such an effect by adding hydrogen to the makeup tank.69
}
There is no testimony from anyone else or other evidence l that connects Frederick to involvement in leak rate test manipulation of this sort.
l The NRC also alleged that improper unlogged water additions were made during five of the leak rate tests that were run while Frederick was on duty. Our own analysis, however, failed to disclose a pattern of water additions that would support a conclusion that Frederick was involved in this type of test manipulation.
An alleged unlogged water addition during the test that was parformed at 15:04 on October 14, 1978, could not be confirmed because of a power level change that took place during the l
EDWARD FREDERICK i
1 middle of the test. This power level change obscured - the )
makeup tank level trace on the strip chart. The trace perturbation caused by this power level change looks quite similar to a water addition, our strip chart analysis also raised questions regarding the NRC allegations that water additions were made during tests of December 23 and December 2
30, 1978. In our view, faulty makeup tank level instrumentation caused the apparent rise in makeup tank level l
that the NRC associated with the water additions in these tests. The unlogged water addition that was allegedly made during the test of February 7, 1979, was also not confirmable because of makeup tank level perturbation reflected on the strip chart. We were able to confirm an unlogged water addition duri..g a test that was run on October 15, 1978, while Faust and Frederick were on shift.74 It should be noted, however, that the alleged addition appears to be part of a
" feed and bleed" operation. These last two tests were both performed and signed during shift turnovers and therefore 5
involved other operators.
l l In addition to those leak rate tests that the NRC found i
! suspicious, we identified at least six others that Frederick was involved in that required further analysis.76 l
f l
l EDWARD FREDERICK Between February 14 and March 28, 1979, logged water i
additions were made during six consecutive leak rate tests run working.77 1
on the shift that Frederick was In cach case, because of the calculation error in the procedure and makeup l tank level transmitter inaccuracy, the water additions significantly reduced indicated levels for unidentified leakage.
When Frederick was questioned about these water additions, ,
l he stated that he did not intentionally add water to the makeup tank during leak rate tests for the purpose of enhancing the test results. Moreover, he testified that he was not even I l
aware at that time that properly accounted for water additions would cause such a result.79 He did state that he was aware of the procedural requirement to avoid water additions during leak rate tests and would generally add water only when it was deemed necessary to maintain proper makeup tank level.80 According to Frederick, he would schedule water additions around leak rate tests.OI When confronted with individual tests involving water additions, he was not able to recall l specifically why the additions were made during the tests.82 He did point out that as time progressed it became necessary to add water very frequently,and it was becoming more difficult to avoid additions during a test.83 L______________.__________________
EDWARD FREDERICK ,
.l Frederick's testimony is supported by our analysis of the leak rate tests involving water additions on his shift.
Five of the six water additions took place during the last 4 Plant records from this period reveal half of March 1979.
that water was being added to the makeup tank several times per l shift to compensate for increasing reactor coolant drain tank collection.85 Four of the six additions apparently were necessary to maintain what was generally accepted as proper makeup tank level.86 While it is not clear why the remaining two water additions were made, there is no evidence to suggest that they were made in an effort to falsify leak rate test j results.
Operator Response to Excessive Leakage The practice of discarding unsatisfactory test results without documentation has made it difficult to identify every :
period when unidentified leakage exceeded 1.0 gpm at TMI-2. l However, we were able to identify and closely examine three !
periods where there were indications of excessive leakage l
available to the operators. Frederick was working during each of these periods. It should be noted that the events of these periods are fully discussed in Volume I of this report. For l
w
EDWARD FREDERICK purposes of this section, these periods are- discussed only to the extent that they relate to action taken by Frederick in I
response to indications of excessive leakage.
l It should be pointed out that Frederick stated that he was' aware in 1978 that, if unidentified leakage exceeded 1.0 gpm, j 4
( he was required to reduce the leakage to within limits or to 8
begin shutting down the plant.
He fur ther stated, however, that he did not remember whether RCS leakage ever exceeded 1.0 gpm. .He did recall doing ,
i leakage searches at various times but did not remember ever experiencing excessive leakage that would have required formal entry into the action statement or a plant shutdown. He ;
also did not specifically remember turning in unsatisfactory l
l 1eak rate tests to his Shift Foreman or in any way being concerned about excessive leakage.90 1
l Despite his failure to recall periods of excessive leakage, there were at least three periods when Frederick was working where there were indications that unidentified leakage exceeded 1.0 gpm.
I l
l EDWARD FREDERICK I
October 16 - 22, 1978 Subsequent to obtaining a successful leak rate test at I 19:28 on October 15, 1978, Operations personnel apparently began to experience RCS leakage problems and difficulty in )
obtaining satisfactory leak rate tests.91 No tests were 2
filed during the first two shifts on October 16, 1978.
Frederick, Faust and Scheimann reported for duty at 15:00 on October 16.' At 19:35 a leak rate test was performed which chowed unidenti fied leakage at 2.56 gpm.94 This test was not signed and apparently not filed as an official leak rate test for that shift. (We believe this test was among those l discovered later by NRC Inspector Donald Haverkamp.)
On October 17, other Operations personnel were attempting to identify the source of RCS leakage and had obtained another unsatisfactory leak rate test (2.07 gpm) before Faust's shift reported for duty.
At 15:00 on October 17, Frederick, Faust, Scheimann, and Zewe again reported for duty.96 Despite the unsatisfactory test results that had been obtained, they did not enter the action statement or proceed to shut the plant down.
L___----__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
~
r.
EDWARD FREDERICK According to plant records, they continued to search. for leakage and operate the plant.99 'They did not file a leak rate test for that shift.99 After reviewing various plant records that were available, Frederick acknowledged in our interview that he was responsible for surveillance on October 16 and that Faust was assigned to j the control room panel.100 He also agreed that, based upon general practice, he would have been the individual who submitted the unsigned test result on that-day. Nevertheless, he stated that he could not recall submitting the test in ;
question, nor could he recall what action, if any, was taken in 01 response to the indications of excessive leakage. He i
acknowledged that plant records revealed a leakage problem but l could offer no explanation for failing to enter . the action 02 statement.
Neither Faust nor Zewe had any recollection of, nor explanation for, failing to enter the action statement at that 03 time.
l 1
l l I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
r 7
]
1 EDWARD FREDERICK !
l December 26, 1978 - January 15, 1979 i l
i Unidentified leakage gradually increased to 1.0 gpm on or about January 3, 1979, and remained above that level . until .
January 15, 1979, when the plant was shut down.104 l l
Frederick and Faust turned in satisfactory leak rate tests (
l on January 4 and 5, 1979, which were performed with the faulty l 05 Thereafter, makeup tank level transmitter. they worked five consecutive assigned shifts during which no leak rate test was filed.106 There are indications that Frederick and his colleagues were aware that RCS leakage was on the increase, particularly by January 11 when Hoyt entered the D-ring and attempted to estimate RCS leakage from the pressurizer valves while they were working.107 Given the evidence regarding the practice of discarding unsatisfactory test results, it is l likely that unsatisfactory results obtained during this time period were discarded without documentation.
It is clear that Frederick and other personnel assigned to .
l l the TMI-2 control room during this period did not take action l to shut the plant down despite the information available to them. 08 l
1 1
l j
i EDWARD FREDERICK Faust testified that .he did recall going through more than )
1 one shif t without being able to get a good leak rate test, but j he could not remember the specifics.109 He further stated that, had he obtained unsatisfactory leak rate tests during }
i this period that he could not invalidate, he would have turned them over to his Shift \ Foreman for appropriate action. ' He stated that this probably occurred, but that he could not really remember any specific incident. Frederick, on the {
i other hand, testified that he did not remember any time period ]
l when there were excessive leakage problems or when it was difficult to get a satisfactory leak rate test. He speculated that failure to obtain a satisfactory leak rate test during this period may have been because they were not working on the l
11pm-7am shift or that the test was not scheduled to be run.
He stated, however, that he really did not remember the events l of January 1979.11 Zewe also testified that he did not recall the specific events of this period.113 March 15 - 28, 1979 l
our analysis indicates that unidentified leakage increased i
during March 1979, until it was close to 1.0 gpm on March 15, and remained fairly constant therea f ter.114 However, as I
22 -
1 EDWARD FREDERICK i
l discussed ir Volume I, operators would have perceived l l l unidentified leakage to be much greater.
I i Faust turned in an invalid negative leak rate test on March I
1 16, 1979, and then Frederick and Faust worked five consecutive 5
nasigned shifts during which no leak rate test was filed. l l
Thereafter, satisfactory 3eak rate tests were filed on their shift on March 24, 25, 27 and 28.116 Each of these yielded l
satisfactory results because water additions during the test caused indicated leakage to be lower.11 Given the testimony, and the available plant documentation, it is highly probable that unsatisfactory test results were obtained by Faust and Frederick during March 1979 and were discarded or not otherwise documented.
There does not appear to have been any information available at that time that would have justified ei ther the discarding of unsatisfactory results or the failure to take required action in response to such results. This is particularly true since during this period the operators were menually re-calculating the test results generated by the computer to correct for a calculation error in the computer t
EDWARD FREDERICK program. Therefore, the operators should have perceived the recalculated results for unidentified leakage to be more accurate and reliable.
EDWARD FREDERICK
]
1 Vol. III, Table 2.
2 Ibid.
3 Ibid.; I l
Vol. IV (MPR Report), Appendix K, Test Numbers 215, i 186, 181, 152, 137, 135, 85, 77, 75, 74, 53, 50, 45, 3. I I
4 Frederick 3/12/85,~p. 123.
5- Vol. III, Table 2.
..1 6 Frederick 3/12/85, pp. 50-51; I 3/14/85, p. 112.
7 Vol. III, Table 2.
8 Ibid.
, 9 Ibid,
! l 10 Ibid, !
11 Ibid.; 1 l
Vol. IV (MPR Report), Appendix K, Test Numbers 85, 77, 75, 74, 73, 60, 56, 53, 50, 45.
12 Vol. III, Table 2; j
Vol. IV (MPR Report), Appendix K. Test Numbers 40, 9.
13 Faust 2/19/85, p. 62.
14 Ibid., pp. 41-42.
15 Frederick 3/12/85, pp. 34-35, 42-43; ,
3/14/85, pp. 110-111.
I
EDWARD FREDERICK 16 Adams 3/19/85, p. 13; Coleman 2/5/85, pp. 32-33; Congdon 2/13/85, p. 34; Faust 2/19/85, pp. 110, 132-133, 136, 138-139; Hoyt 2/26/85, pp. 4,8; Illjes 2/7/85, pp. 11-13, 15-16; McGovern 2/6/85, p. 109; Mehler 2/28/85, pp. 57-60, 63-64, 66; Miller, A. 3/21/85, pp. 20-23; Zewe 2/27/85, pp. 10-11, 37.
17 Vol. IV (MPR Report),Section V.
18 Frederick $/12/85, pp. 14-15.
19 Ibid _., p. 16.
20 Ibid., p. 17.
21 Ibid., p. 17.
22 Frederick 3/12/85, pp. 17-18, 34-35.
23 Frederick 3/12/85, pp. 17-18.
l l
24 Frederick 3/12/84, pp. 76-77; 3/14/85, pp. 76-77 25 Frederick 3/12/85, pp. 80-81; 3/14/85, p. 194; Faust 2/19/85, pp.99-100.
26 Frederick 3/12/85, pp. 82, 90-91.
27 Ibid., p. 90.
28 Ibid., pp. 82-83.
29 Ibid., p. 91.
30 Faust, 2/19/85, pp. 94-95, 101.
31 Frederick 3/12/85, p. 92.
32 Ibid., pp. 44y 93. ,'
~
t
[ corrected 1/17/86]
l' EDWARD FREDERICK l
i 16 A ams 3/19/85, p. 13; Co eman 2/5/85, pp. 32-33; Congdon 2/13/85, p. 34; Faus- 2/19/85, pp. 110, 132-133, 136, 138-139; Hoyt 26/85, pp. 4,8; Illjes /7/85, pp. 11-13, 15-16; McGoverng 2 /6/85, p. 109; Mehler 2/ 8/85, pp. 57-60, 63-64, 66; Miller, A. 3/21/85, pp. 20-23; Zewe 2/27/8 pp. 10-11, 37.
17 Vol. IV (MPR port),Section V.
18 Frederick 3/12/8 pp. 14-15.
19 Ibid., p. 16.
20 Ibid., p. 17.
21 Ibid., p. 17.
23 Frederick 3/12/85, pp. 34- b; 3/14/85, pp. 86-8 23 Frederick 3/12/85, pp. 17-18.
24 Frederick 3/12/85, pp. 76-77; 3/14/85, pp. 76-77.
l l
i 25 Frederick 3/12/85, pp. 80-81; 3/14/85, p. 194; Faust 2/19/85, pp.99-100.
26 Frederick 3/12/85, pp. 82, 90-91.
27 Ibid., p. 90.
28 Ibid., pp. 82-83. ,
1 29 Ibid., p. 91.
30 Faust, 2/19/85, pp. 94-95, 101.
31 Frederick 3/12/85, p. 92.
32 Ibid., pp. 44, 93.
l
- ----- _ - - _ _ - - - - - - - - - -- J
I ,
I EDWARD FREDERICK j
[ 33 Frederick 3/12/85, pp. 93-96; ;
l 3/14/85, pp. 75-76.
34 Frederick 3/12/85, p. 85.
35 Ibid., pp. 85-86.
36 Frederick 3/14/85, p. 76. ,
37 Ibid., pp. 76-77.
38 Frederick 3/12/85, pp. 16-17.
39 Ibid., pp. 8-13.
40 Frederick 3/14/85, pp. 3-4.
41 Frederick 3/12/85, pp. 11-12.
42 Frederick 3/12/85, pp. 59-60; 3/14/85, pp. 82-83; Vol. IV (MDR Report), Appendix K, Test Number 74.
43 Frederick 3/12/85, pp. 78-79.
44 Vol. III, Table 2; Vol. IV (MPR Report), Appendix K, Test Numbers 186, I 179, 178, 152, 94, 85, 75, 74, 73, 4.
45 voi, Iy (gpR Report), Appendix K, Test Numbers 186, 152, 85, 75, 74, 50.
46 Ibid., Test Number 186.
47 TMI-2 Surveillance procedure 2301-3D1, RCS Inventory, Rev. 2, May 4, 1978, p. 2, Section 4.2, (Tab 19).
48 Vol. IV (MPR Report), Appendix K, Test Numbers 152,-77.
49 Ibid., Test. Numbers 85, 75,.74.
50 Ibid., Test Number 50.
51 Frederick 3/14/85, pp. 122-123.
l l
l, t l i
l EDWARD FREDERICK 52 Frederick 3/12/85, pp. 106-107, 109-113; j 3/14/85, pp. 21-26, 44-49, 61-73, 136, 145, '
180.
53 Vol. IV (MPR Report), Appendix K, Test Numbers 85, 78, 75, 74. 1 I
54 Frederick 3/12/85, pp. 10, 62. l 55 Ibid., pp. 29-31. ,
I 56 Ibid., p. 30.
I 57 Ibid., p. 40, j 1
58 Ibid., pp. 41-42. )
l 59 Frederick 3/14/85, p. 26.
60 vol, Iy (gpR Report), Appendix K, Test Number 94; i Frederick 3/14/85, p. 17. ,
l 61 Frederick 3/14/85, pp. 17-19.
62 Vol. IV (MPR Report), Appendix K, Test Number 85; l Frederick 3/14/85, p. 21. ,
63 Frederick 3/14/85, pp. 21-26.
64 Vol. IV (MPR Report), Appendix K, Test Numbers 77, 75, 74.
65 Frederick 3/14/85, pp. 58-73, 103-105.
66 Ibid _., p. 106.
67 Vol. IV (MPR Report), Appendix K, Test Number 78.
68 Frederick 3/12/85, pp. 32, 68-69.
69 Faust, 2/19/85, p. 25.
70 Vol. IV (MPR Report), Appendix K, Test Numbers 152, 150, 85, 78, 50.
71 Ibid., Test Number 152.
)
EDWARD FREDERICK 72 Ibid., Test Numbers 85, 78.
73 Ibid., Test Number 50.
74 Ibid., Test Number 150.
75 Vol. III, Table 1.
l 76 Vol. IV (MPR Report), Appendix K, Test Numbers 40, 9, 4, 3 .,
2, 1.
77 Ibid.
I 78 Frederick 3/14/85, pp. 190-193. l l
79 Frederick 3/12/85, pp. 32-33, 162.
l 80 Ibid., pp. 32-33, 61.
81 Ibid., p. 62.
82 Frederick 3/14/85, pp. 164, 167, 170-171, 174, 176, 179, l
186.
83 Frederick 3/12/85, pp. 63-64.
84 Vol. IV (MPR Report), Appendix K, Test Numbers 9, 4, 3, 2, 1.
85 Vol. III, Table 4.
86 Vol. IV (MPR Report), Appendix K, Test Numbers 9, 3, 2, 1.
87 Ibid., Test Numbers 40, 4.
l 88 Frederick 3/12/85, p. 6.
l 89 Ibid., pp. 100-101.
90 Ibid., pp. 74, 101.
l 91 Vol. III, Table 4; Vol. IV (MPR Report), Appendix K, Test Number 150.
92 Vol. III, Table 1.
93 Ibid., Table 2.
[ corrected 1/17/86) 4
- -__ __ D
l l
EDWARD FREDERICK 72 Ibid., Test Numbers 85, 78.
( 73 bid., Test Number 50.
74 Ib 4., Test Number 150.
75 Vol. III, Table 1.
76 Vol. I (MPR Report), Appendix K, Test Numbers 40, 9, 4, 3, l
2, 1.
77 Ibid.
18 Frederick 3/1 /85, pp. 190-193.
l t
79 Frederick 3/12/ , pp. 32-33, 162.
80 Ibid., pp. 32-33, 61.
81 Ibid., p. 62.
82 Frederick 3/14/85, pp. 164, 167, 170-171, 174, 176, 179, 186.
83 Frederick 3/12/85, pp. 63- 4.
84 1. IV (MPR Report), Append K, Test Numbers 9, 4, 3, 2, 85 Vol. III, Table 4.
86 Vol. IV (MPR Report), Appendix K, st Numbers 9, 3, 2, 1.
87 Ibid., Test Numbers 40, 4.
88 Frederick 3/12/85, p. 6.
89 Ibid., pp. 100-101.
90 Ibid., p. 101.
91 Vol. III, Table 4; Vol. IV (MPR Report), Appendix K, Test Number 150.
92 Vol. III, Table 1.
93 Ibid., Table 2.
EDWARD FREDERICK 94 Vol. IV (MPR Report), Appendix K, Test Number 149.
95 Vol. III, Table 4; ,
I Vol. IV (MPR Report), Appendix K, Test Number 148. ]4 96 Vol. III, Table 2. l l
97 Frederick 3/12/85, pp. 126-130. l 98 Vol. III, Table 4.
99 Ibid., Table 2.
100 Frederick 3/12/85, pp. 121-123.
i 101 Ibid., p. 125. i 102 Ibid., p. 130.
l 103 Faust 2/19/85, p. 155.
Zewe 2/27/85, pp. 70-71.
l 104 voi, yy (gpR Report), Figure IV-20.
105 Ibid., Appendix K, Test Numbers 74, 73.
l 106 Vol. III, Table 2.
l 107 Frederick 3/14/85, pp. 120-121; Faust 2/20/85, pp. 36-40.
108 Vol. III, Table 4.
109 Faust 2/20/85, pp. 37-38.
110 Ibid., pp. 39-40.
111 Ibid., p. 41.
113 Frederick 3/14/85, pp. 109-111.
113 Zewe 2/27/85, p. 85.
114 Vol. IV (MPR Report), Figure IV-20.
115 Vol. III, Table 2; Vol. IV (MPR Report), Appendix K, Test Number 9.
l
EDWARD FREDERICK 116 Ibid., Test Numbers 4, 3, 2, 1.
117 Vol. III, Table 2; Vol. IV (MPR Report), pp. VI.3 - VI.7.
?
L
I I
1 JACK GARRISON becan employment with Metropolitan Edison i Company in April 1973. He is presently employed by GPU Nuclear
]
I as an Engineering Assistant. During all of 1978 he was !
assigned to TMI-2 as a Shif t . Test Engineer. From . January 1, 1979, until the accident in March 1979, Garrison was in- i training, full time, for his Senior Reactor Operator's License.1 l
Accordina to Garrison, durina TMI-2 operation, he had no involvement in either the performance or oversicht of leak rate testina at TMI-2.2 Although Garrison testified that, as a Shift Test Engineer, he did spend some time in the control i
room, he stated that he never witnessed the performance of-a leak rate ' test, nor did he observe any operator misconduct' I related to leak rate testing.3 i
He explained that because of the nature of his duties, he did not regularly work with the same control room shift and he did not have much direct involvement with Control Room Oparators.4 Garrison further stated that he had no discussions with anyone that made him aware of improper leak rate testino practices or test manipulation.5 Additionally, '
1 l
i i
L_ _________m_.______ _ _ _ _ z- _. -
JACK GARRISON he stated that he had no reason to believe that company manacement was aware of, or condoned, operator misconduct.6 He further stated that he did not think that it had been I company policy to ionore limiting conditions for operation in order to keep TMI-2 on line.7 l
l l Garrison was questioned specifically about his knowledae of the events of the week of October 16, 1978, since plant records revealed that he was working at that time.8 I
After reviewina the Shift Test Engineers' Loo, Garrison i
acknowledged that he was workina the 11pm-7am shift at TMI-2 l durina that week.9 However, he testified that he had no i
recollection of any reactor coolant system (RCS) leakage problems or difficulties in obtaining satisfactory leak rate test results.10 He also stated that he would have become aware of these kinds of problems only if the Operations Staff made plans to shut down the plant, thereby affectino his test schedule.11 He did not remember any such plans or any discussions regarding a possible shut down of the plant.12 After reviewino his loc for that time period, he stated that he osw no evidence that there was an entry into the action statement or a reduction in power brought about by excessive RCS leakage.13 Indeed, Garrison testified that he did not JACK GARRISON recall ever being in the action statement because of excessive RCS leakage while he was assigned as a Shift Test Enaineer at TMI-2.14 On January 1, 1979, Garrison began training for his Genior Reactor Operator's License and did not work at TMI until after the accident.
In view of the forecoing, we have concluded that the evidence does not show that Garrison participated in or condoned improper lesk rate testinq practices.
I i
{
i JACK GARRISON 1 Garrison 2/5/85, p. 8.
2 Ibid., p. 7.
3 Garrison 9/28/83, p. 11; 2/5/85, p. 7.
4 Ibid., pp. 6-9.
5 Garrison 9/28/83, pp. 31-33, 39, 42-43.
6 Ibid., pp. 31, 43.
)
l 7 Ibid., p. 42; I
Garrison 2/5/85, p. 31.
8 Garrison 2/5/85, pp. 15-16.
i 9 TMI-2 Shift Test Engineers Log, October 16, 1978, (Tab 50).
Garrison 2/5/85, p. 16.
10 Ibid., p. 17 11 Ibid., p. 17.
12 Ibid., pp. 17-18.
13 Ibid., p. 20.
14 Ibid., p. 17
[ corrected 1/17/86]
- . - . . . _ _ _ _ _ 1
JACK GARRISON 1
Garrison 2/5/85, p. 8.
2 bid., p. 7.
3 Ga ison 9/28/83, p. 11; 2/5/85, p. 7.
4 Ibid., pp. 6-9.
5 Garrison 9/28/83, pp. 31-33, 39, 42-43.
6 Ibid., pp. 31, 43.
7 Ibid., p. 42 8
Garrison 2/5/85, pp. 15-16.
9 TMI-2ShiftTestEkgineersLog, October 16, 1978, (Tab 50).
Garrison 2/5/85, p. 1 10 Ibid., p. 17.
11 Ibid., p. 17.
12 Ibid., pp. 17-18.
13 Ibid., p. 20.
14 Ibid., p. 17.
T
Ii<
CARL GUTHRIE began employment with- Metropolitan Fdison Company on February 2, 1971. Between March 1978 and March 1979, he worked as a Shift Foreman assigned to.TMI-2. During 1978, he was responsible for supervising several Control Room Operators on different shifts. But by'1979, .he ~ was ' regularly assigned as the ' Shi f t- Foreman for the shift comprised of Hugh McGovern, Leonard Germer and Earl Hemmila, Kenneth Bryan and Bernard Smith were his Shift Supervisors during most'of this time.
l Analysis of employee testimony, Reactor Coolant Inventory l
Balance tests (leak rate tests) and related plant documents reveals that Guthrie failed to properly supervise the performance of leak rate tests and also failed to ensure that required action was taken in response to indications of reactor coolant system (RCS) leakage during October 1978 and' March 1979. There is insufficient evidence to - 's uppor t a conclusion that Guthrie participated in, or knowingly tolerated, l ,
manipulation of leak rate test results.
[ corrected 1/17/86) 1
\
I s
\ -
\
l l
employment with Metropolitan Edison CARL GUT IE began Company on Feb ary 2, 1971. Between March 1979 and March 1979, he worked a Shift Foreman assigned to TMI-2. During l
- 1978, he was respo ble for supervising several Control Room l Operators on differen shifts. But by 1979, he was regularly assigned as the Shift F
\
eman for the shift comprised of Hugh 1 Kenneth Bryan and McGovern, Leonard Germer ad Earl Hemmila.
I Bernard Smith were his Shif' Supervisors during most of this time.
i Analysis of employee testimony, Reactor Coolant Inventory !
Balance tests (leak rate tests) and related plant documents p perly supervise the .
reveals that Guthrie failed to performance of leak rate tests and also iled to ensure that required action was taken in response to ind' ations of reactor leakage during October 1978 and March fi coolant system (RCS)
There is insufficient evidence to suppor a conclusion 1979.
or knowingly tolerated, Guthrie participated, in that manipulation of leak rate test results. i i
)
- ~ - - - _ _ _ _- . _ _ _
CARL GUTHRIE Supervision of Leak Rate Testing There is substantial evidence that Guthrie failed to properly supervise the performance of leak rate tests that were conducted on his shift. He tolerated and participated in a ,
practice of discarding all unsatisfactory test results without documentation. He also approved of the filing of numerous satisfactory test results which were clearly invalid and which did not accurately measure reactor coolant system leakage.
t It is apparent from Guthrie's testimony that he was not I
seriously committed to ensuring that leak rate tests were properly conducted in order to measure RCS leakage.
He testified that although the leak rate test was the primary method for measuring RCS leakage at TMI-2, there were problems associated with running the tests.1 According to Guthrie, lea 1 rate test results tended to be unpredictable and quite variable even within short time frames.2 Frequently, test results could not be substantiated with readings from other plant instruments.3 Guthrie estimated that, during some periods, approximately 30 percent of the results obtainedwere deemed to be inaccurate. He stated that because so many results were obtained that could not be 2-
i i
CARL GUTHRIE the test was viewed as having no validity.5 )
' substantiated, Ultimately, the leak rate test was regarded as more of a tool than a " holy and sacred" legal document.6 l
Accoraing to Guthrie, the problems associated with leak rate testing were common knowledge at TMI-2 and all Operations Department personnel, including the Supervisor of Operations, J were aware of them. In fact, Guthrie stated that he, other Shift Foremen, and Shift Supervisors discussed the problems associated with leak rate testing and complained about not being able to accurately measure RCS leakage. Although he could not remember specific conversations, he knows that they l never really resolved anything in this regard.8 I
i Given Guthrie's general attitude about leak rate testing, it is not surprising that he did little to ensure that leak rate testing was properly conducted on his shift.
l According to Guthrie's testimony, Control Room Operators per fortned leak rate tests with little oversight from Shift Foremen and Shift Supervisors. Guthrie indicated that his primarily of making sure that a test was role consisted parformed on every shift and that test -results were complete and met acceptance criteria.
CARL GUTHRIE he conceded that it was the practice to discard unsatisfactory test results and that he personally discarded some unsatisfactory test' results as well.ll While Guthrie e
initially maintained that most of the tests that were thrown away were'first deemed to be invalid, he later admitted that he '
was not aware of any unsatisfactory tests that were filed or 12 stated, however, that kept for any purpose. He unsatisfactory tests were brought to the attention of his Shift Supervisor in order to make him aware that they might have .
3 I exceeded limiting conditions for operations.
I r
In addition to the discarding of all unsatisfactory test ]
results, Guthrie admitted knowing that no Exception and Deficiency reports were filed and no log entries were' made l documenting the test results that were being thrown away.14 1
Nevertheless, Guthrie denied that the practice of discarding tests was designed to conceal unsatisfactory information regarding RCS leakage from the NRC. Instead, he maintained the position that the leak rate test was treated i differently than other surveillance because of the nature of the t'est and the frequency with which it was performed.16 He also reiterated that most unsatisfactory test results could not ,
be substantiated by other plant instruments.
I CARL'GUTHRIE I
1 Testing patterns on shifts supervised by Guthrie are . not l
completely consistent . with his testimony. There were no filed tests showing leakage in excess of 1.0 gpm 'and~ there were many shifts in which no leak rate test was-filed'at all..
TMI-2 records indicate that between March 1978 and March of 1979, Guthrie reported for duty-and worked as a Shift Foreman -
1 on approximately 78 shifts during which RCIB tests presumably could have been performed. Despite Guthrie's ' stated practice of ensuring that a leak rate test was performed at least once per shift, only 21 leak rate tests were filed'during j all the shifts supervised by Guthrie. Guthrie signed as the approver of nearly all of these tests. ,
l Aside from the fact that no tests were ' filed' showing no unsatisfactory leakage, there are obvious : patterns associated with leak rate testing supervised by Guthrie.
1 Although there are many 7am-3pm shifts in which no tests were filed, there were also several 3pm-11pm and 11pm-7am tests which did not produce.. filed tests as well. There were also l' several instances of consecutive assigned shifts supervised by l Guthrie for which no leak rate tests were filed. These gaps in filsd tests appear throughout the entire year of operation.
l c
'_. _ - . _ _ _ . - - . . - - _ . _-_...__.--.-.-J
CARL GUTHRIE There is one period between February 3. and 16, 1979, when Guthrie's shift filed fairly regular test results. During that time, a test was filed on nine of the ten shifts worked by Guthrie's shift.
on the other hand, there is also one period, between February 16, 1979, and March 17, 1979, when Guthrie _ supe vised 13 consecutive assigned shifts without filing a test result.20 Our analysis reveals that this was a period in which increased reactor coolant drain tank colle'etion would have made it very difficult to obtain a satisfactory leak rate test because of a calculation error in the procedure. Guthrie l
testified tha t he recalls that this was in fact a period when-it was particularly dif ficult to obtain satisfactory leak rate I l
test results.
In addition to tolerating, and participating in, the f discarding of all unsatisfactory test results obtained on his shift, Guthrie approved the filing of numerous satisfactory i
i leak rate test results that were inaccurate or performed in violation of a test procedures. Almost half of the tests that ,
Guthrie approved .should have been determined' to be invalid.22 Three of the tests approved by. Guthrie . contained obviously inaccurate information on the computer . printout
f l
t l CARL GUTHRIE itself. Several satisfactory test results approved between December 16, 1978, and December 31, 1978, involved tests performed with faulty makeup tank level instrumentation.24 l The last five tests that Guthrie approved between March 17, l
1979, and March 27, 1979, involved logged water additions i during the test that caused the unidentified leakage result to be lower because of makeup tank level instrumentation i
i problems.25 When confronted with these inaccurate test results, Guthrie generally conceded that they were invalid and should not have been filed. He stated that he must have approved some of the tests simply because he did not notice the discrepancies in the test data. Moreover, Guthrie stated it was the practice at the time to file satisfactory test results without questioning their reliability if there were no indication of a I problem. Yet, Guthrie did testify that he was aware in 1978 that one of the makeup tank level transmitters was not functioning properly.20 He denied, however, that anyone he i knew of had ever intentionally run leak rate tests using the faulty transmitter to influence test results. He could not I
explain why so many tests came to be run on the faulty 9
transmitter.
i 1
l-
CARL GUTHRIE Insofar as the water additions were concerned, Guthrie testified that he felt that water should not be added during a leak rate test unless absolutely necessary. According to him, as long as the water addition was nece;sary, and accurately accounted for in the test calculation, it would not be improper.30 He also indicated that he was not aware in 1978 that accounted-for water additions could favorably influence test results. Consequently, he would not have questioned operators regarding water additions made during tests since he would have assumed they were necessary for inventory control.31 Manipulation of Test Results Our investigation did not produce sufficient evidence to support a conclusion that Guthrie tolerated, or participated in, the intentional manipulation of leak rate test results.
The NRC alleged that hydrogen was 'a'dded during three leak rate tests that were performed under Guthrie's supervision on October 20, 1978, December 30, 3.973, and March 21, 1979.
\
t CARL GUTHRIE The test of October 20, 1978, which was performed by Bocher and approved by Guthrie, did in fact include two logged hydrogen additions.33 According to our analysis, however, these additions did not have a substantial influence on the test result. Moreover, this test was one of several tests in October that were rour.ded off to 0.0 gpm by the computer, l thereby making test manipulation less likely. It should be noted, however, that Hartman has implicated Bocher in test i
.l manipulation.
The test of December 30, 1978, was performed by McGovern with the faulty MUT level transmitte:r . 36 Guthrie was on shift when this test was started, but Adams relieved him before its completion and actually approved the test for filing. The obvious disparity between the two makeup tank level readings, j
and the fact that no hydrogen addition was logged, makes it impossible to confirm whether an addition was in fact made.
l Our analysis of the MUT level strip chart trace, however, suggests that faulty instrumentation would have had a much greater effeet on the test results than aa >: logged hydrogen addition.
I
CARL GUTHRIE j i
The test of March 21, 1979, was performed by Hemilla. and approved by Guthrie. The Control Room Log does show that a i hydrogen addition was made during the test; however, our strip i_
chart analysis reveals that it had little or no ef fect on the leak rate test results.37 l
When questioned about these tests, Guthrie denied !
involvement in, or knowledge of, test manipulation through the addition of hydrogen. He stated that in 1978 he was under j 1
the impression that hydrogen additions to the makeup tank would I produce only a short temporary offset to the makeup tank level i trace which would not influence test results.3 He was not l able to explain why it would have been necessary to add hydrogen during' these tests, but stated that he did not believe i that hydrogen additions were prohibited by the leak rate test procedures.40 I i
I I He stated that, given his knowledge at the time, he probably would not have even known that hydrogen was added during a test.
I During our investigation we found no direct evidence tending to refute his testimony.
The NRC also alleged that unlogged or underrecorded water additions were made during eight of the tests that were l
CARL GUTHRIE performed while Guthrie was en outy.42 Based upon 'our analysis of the strip. charts and related logs, the alleged additions of November 9, December 24 and February 9 were actually made outside the test period but were believed to have been made during the test because of strip chart time 43 errors.
The makeup tank level during the test of February 6, 1979, was so heavily influenced by an apparent switch from automatic to manual controls for the RCS that we were unable to confirm a i water addition during that test alleged by the NRC.
i We were able to confirm only one unlogged and unaccounted-for water addition during the test of October 15, 1978, performed while Guthrie was on duty.45 Guthrie had no recollection of this period and test records reveal that Shift Supervisor Bernerd Smith actually approved this test in place of Guthrie.
I i Water additione of March 19, 1979, and March 21, 1979, were logged and accounted for in the leak rate tests, but were-allegedly understated according to the NRC.46 We do not believe that this was the case. On the contrary, it appears l
! i
( that the discrepancy between the amount of water recorded by l
CARL.GUTHRIE the operators during these tests and that reflected in the strip charts was actually caused by the inaccurate makeup tank level instrumentation described in Volume I. As we discussed previously, Guthrie indicated that he was not aware of this problem and did not have reason to . believe that these water additions were unnecessary or improper.47 Plant records tend to support his testimony. Water additions were in fact being . made quite frequently during the last half of March 1979, and they were approaching a frequency which understandably could have overlapped with the running.of leak rate tests.48 Five tests involving water additions were made on Guthrie's shift between ' March 17, 1979, and March 29, 1979.49 Two of the tests included water additions which appear to have been i
necessary to maintain proper MUT level. O While it is not clear why the remaining additions were made, there is no evidence to' suggest that they were made in an effort to falsify test results.
i i
CARL GUTHRIE Response to Excessive Leakage The practice of discarding unsatisfactory test results without documentation has made it difficult to identify every brief period when unidentified leakage may have exceeded 1.0 gpm at TMI-2. However, we have been able to identify and closely examine three periods when there were indications that unidentified leakage exceeded 1.0 gpm. Guthrie was on duty l during two of these periods, in October 1978 and March 1979.
l The events of these periods, and the basis for their selection, are more fully discussed in Volume I of this
( report. For purposes of this section, these periods are discussed only to the extent that they relate to action taken by Guthrie in response to the indications of excessive leakage.
First of all, it should be pointed out that Guthrie recognized his responsibility for monitoring and evaluating RCS leakage as a Shift Foreman at TMI-2 in 1978 and 1979. Fe also understood that it was his responsibility to ensure that if limiting conditions of operation for RCS leakege were exceeded, 1
appropriate action would be taken by plant personnel.
[ corrected 1/17/86]
CARL GUTHRTE Respons to Excessive-Leakage l
'The pra tice of discarding unsatisfactory test results l
without docume tation has made it difficult to identify every brief period wh unidentified leakage may have exceeded 1.0 l
gpm at TMI-2. H ever, we have been able to identify and closely examine thre periods when there were indications that unidentified leakage e ceeded 1:00 p.m. Guthrie was on duty l during two of these perio , in October 1978 and March 1979.
The events of these pe ods, and the basis for their selection, are more fully di ussed in Volume I of this l report. For purposes of this ection, these periods are )
{ i J
! discussed only to the extent that t ey relate to action taken l
by Guthrie in response to the indicatio of excessive leakage.
i First of all, it should be pointed out that Guthrie recognized his responsibility for monitoring a d evaluating RCS i leakage as a Ehift Foreman at TMI-2 in 1978 and 979. He also understood that it was his responsibility .to en ure that if l
limiting conditions of operation for RCS leakage wer exceeded, l
appropriate action would be taken by-plant personnel.51 CARL GUTHRIE According to Guthrie, if limiting conditions of operation were exceeded, it would be necessary to reduce the leakage to within limits or to shut down the plant within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />.52 Unless there were an emergency, Guthrie felt that any decision to shut down the plant would require the concurrence of his Shift Supervisor.53 Despite his basic knowledge of the action requirements of the Technical Specifications for RCS leakage, it does not appear that Guthrie made efforts to ensure that required action was taken in response to indications of excessive leakage.
October 16-22, 1978 On October 15, 1978, Operationn personnel apparently began to experience difficulty in obtaining satisfactory leak rate test results.54 At 20:28, a satisfactory leak rate test result was obtained boeduse of an unaccounted-for water addition during the test.55 For some reason, this test result was not signed until sometime during the 11pm-7an shif t on October 16, 1978 when Guthrie's shift was working. However, the test was signed by Shift Supervisor Bernard Smith, instead of Guthrie. Neither Guthrie nor Smith can recall the events of this period.56
.1 l.
I l
CARL 6,THRIE i
l In any event, there was no leak rate test filed for the next shift but an unsigned test result was obtained during the 57 I 3pm-11pm shift showing unidentified leakage at 2.56 gpm.
Guthrie's shift reported back to work on the llpm-7am shift on !
October 17, 1978. No satisfactory leak rate test result was filed and there are entries in various plant records which reveal that Guthrie's shift was searching for the source of l
unidentified leakage.58 Despite the perceived leakage, the time elapsed since the last satisfactory test, and the intervening test of the 16th 1
! showing leakage at 2.56 gpm, there is no indication that l efforts were underway to shut down the plant. Company records j do not reveal any of ficial entry into the action statement.
On the day shift or October 17, 1978, Coleman performed a leak rate test showing unidentified leakage at 2.07 gpm. 59 on the 3pm-llpm shift, no leak rate test was filed and plant records continue to reveal that there were ongoing attempts to identify leakage.60 Guthrie and his shift reported for duty again for the 11pm-7am shift of October 18th. An unsigned leak rate test was completed at 06:17 showing unidentified leakage at 1.775 61 gpm.
CARL GUTHRIE The morning report and the attached turnover notes submitted by . Bryan at the end of the shift include a comment:
"Still could not get a leak rate - 1900 today is~ deadline.Doing hand calculations. Can not find leak -
Don't believe it's in the RB [ reactor building]." There is nothing in plant records to document that Guthrie's shift was proceeding to shut down the plant or otherwise take formal action in response to the perceived leakage.
The unsigned leak rate test that was submitted contains a handwritten note that says: " rounds off high but is corrected by leak rate 10/18/78 7:35:27 start time i.e. into action statement at 5:13:02 out of it at 7:35:27." Guthrie has stated l
! that he does not specifically recall the test in question but does not believe that his shift entered the action statement at the time noted.63 He further said that he did not recognize the handwriting on the test and thought that perhaps the entry was written after the fact.64 In any event, he could not explain specifice.lly why he did not cause the required action to be taken. Shift Supervisor, Kenneth Bryan, refused to be interviewed during this investigation.
1 CARL GUTHRIE l
March 1 - March 28, 1979 )
]
Guthrie was not regularly assigned to the control room during January 1979, but was continually working in the control room during March 1979 when there were indications that leakage i
exceeded 1.0 gpm. Our analysis indicates that unidentified
\
leakage increased during March 1979, until it was close to 1.0 J gpm on March 16,1979, and remained faulty constant thereafter. J i
I However, for reasons discussed in Volumn I, operators would have perceived unidentified leakage to be much greater.
Between March 1, 1979, and March 13, 1979, Guthrie l supervised 11 consecutive shif ts during which no leak rate test was filed. Based upon his own testimony and the testimony of others, it is highly probable that numerous unsatisfactory test i results were obtained on Guthrie's shift during this period which were discarded.
1 I
Guthrie's shift obtained several satisfactory test results l
during the latter part of March but these tests were all i j
influenced by water additions which caused indicated unidentified leakage to be understated. This understatement was due to makeup tank level instrumentation problems and the calculation error in the procedure." There were also four shifts worked during this period in which Guthrie and his subordinates did not file satisfactory leak rate tests.
CARL GUTHRIE Plant records reveal that there were indications of excessive leakage during this period that should have triggered some documented action by Operations personnel.66 For example, Guthrie and his shift responded for duty on March 23, 1979 at 23:00. There had not been a satisfactory leak rate test for almost 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> since McGovern and Guthrie filed a test result at 03:50 on March 22, 1979.67 Guthrie testified that he probably would have been aware of this fact through his
! review of the status board in the TMI-2 control room. 68 ggg entries completed by McGovern reveal that over 3,000 gallons of water were added to the makeup tank on this shift.59 No leak l rate test was filed and the Daily Plant Status Report for that shift carried over the leak rate from March 22, 1979. O Although Guthrie remembered that it became more difficult to obtain satisfactory leak rate tests shortly before the accident, he could not specifically recall any time period in 1
which unidentified leakage exceeded 1.0 gpm. Never theles s ,
it is clear that he worked during some periods when there were indications of excessive leakage and that he failed to ensure that proper action was taken by his subordinates in response to such indications.
I l
CARL GUTHRIE Guthrie acknowledged that because of the problems l
cceociated with leak rate testing, he and his colleagues could not really be certain that unidentified leakage was not excoeding the 1.0 gpm limit at any given time. Since there l was so little confidence in the leak rate test, unsatisfactory l ro=ults would trigger a search for leaks, but not a shutdown of the plant.73 However, during March 1979, operators were j manually recalculating test results to correct for a f l
calculation error in the computer program. Therefore, the operators should have perceived the test results to be more accurate and reliable, and responded to results in excess of 1.0 gpm by entering into the action statement.
Guthrie stated that he vaguely recalls a couple of occasions when he and his colleagues entered the action statement in response to excessive RCS leakage. However, all i
he could remember about these occasions was that they did a lot of searching for leaks at taduced power.74 Guthrie further recalls times when he expressed concerns to his Shift Supervisor about continued opera tion of the plant with unsatisfactory 1mak rates. According to him, he felt that during these times, a plant shutdown may have been justified because a satisfactory leak rate could not be CARL GUTHRIE i demonstrated.75 His Shift Supervisors generally too^k the position that a shutdown was not necessary and that they should l
scarch for, and quantify, more identified leakage and perform cdditional leak rate tests.76
~
l l
l Guthrie stated that Smith and Bryan were the only Shift ,
)
l Supervisors that he could remember working with, but he could !
not recall with which one he had such conversations.77 In his interview, Smith conceded that it was the practice l
l on his shift for CRO's to bring possibly valid unsatisfactory l
test results to his attention to determine if the plant should be shut down. O Bryan refused to be interviewed during this investigation.
l l
l l
CARL GUTHRIE 1 Guthrie 2/12/85, pp. 5, 17.
2 Ibid., pp. 15-16.
3 Ibid., p. 22.
4 Ibid., p. 19.
5 Ibid., p. 22, i 6 Ibid., pp. 28, 31.
l l
l 7 Ibid., p. 18.
8 Ibid., p. 30.
9 Ibid., p. 7 10 Ibid., p. 8.
11 Ibid., pp. 19-20.
l 12 Ibid., p. 26.
13 Ibid., p. 26.
14 Ibid., pp. 20-22.
15 Ibid., p. 22.
16 Ibid., p. 21.
17 Vol. III, Table 2.
18 Guthrie 2/12/85, p.7.
19 Vol. IV (MPR Report), Appendix K. Test Numbers 59, 57, 55, 52, 51, 49, 47, 42, 37.
20 Vol. III, Table 2.
I 21 Guthrie 2/12/85, p. 19.
22 Vol. III, Table 2.
23 Vol. IV (MPR Report), Appendix R, Test Numbers 214a, 124, 117.
l
-2 ~
[ corrected 1/17/86]
l
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l l
CARL GUTHRIE i
1 Guthrie 2/12/85, pp. 5, 17.
2 I id., pp. 15-16.
3 Ibi , p. 22.
4 Ibid., p. 19.
5 Ibid., . 22.
6 Ibid., pp. 28, 31.
- 7 Ibid., p. 18 8 Ibid., p. 30.
9 Ibid., p. 7.
10 Ibid., p. 8.
11 Ibid., pp. 19-20.
12 Ibid., p. 26.
13 Ibid., p. 26.
14 Ibid., p. 15.
15 Ibid., p. 22.
16 Ibid., p. 21.
17 Vol. III, Table 2.
18 Guthrie 2/12/85, p.7.
19 Vol. IV (MPR Report), Appendix K, Test Num ers 59, 57, SS, 52, 51, 49, 47, 42, 37.
20 Vol. III, Table 2.
21 Guthrie 2/12/85, p. 19.
22 Vol. III, Table 2.
23 vol, yy (MpR Report), Appendix K, Test Numbers 214a, 124, 117.
l .
l l CARL GUTHRIE l 24 Vol IV (MPR Report), Appendix K, Test Numbers 94, 85, j 84, 78, 77.
l 25 Ibid., Test Numbers 8, 7, 6, 5, 2.
26 Guthrie 2/12/85, pp. 54, 57.
27 Ibid., p. 24, 28 Ibid., pp. 16, 62.
1
! 29 Ibid., p. 62.
30 Ibid., p. 72.
31 Ibid., pp. 72-73.
32 Vol. IV (MPR Report) Appendjx K, Test Numbers 140, 78, 6.
33 Ibid., Test Number 140.
34 Ibid., pp. VII.1 - VII.5, Table VII-1.
35 Hartman 7/26/83, pp. 1, 6; 7/16/82, pp. 109, 113, 132, 140, 142; 8/18/82, pp. 261-262.
36 Vol. IV (MPR Report), Appendix K, Test Number 78.
37 Ibid., Test Number 6.
38 Guthrie 2/12/85, pp. 65, 68.
39 Ibid., p. 17.
40 Ibid., p. 52.
41 Guthrie 2/12/85, pp. 51-52, 65, 67-68.
42 Vol. IV (MPR Report), Appendix K, Test Numbers 150, 118, 85, 84, 78, 52, 47, 7.
-43 Vol. IV (MPR Report), Appendix K, Test Numbers 118, 84, 41.
44 Ibid., Test Number 52.
l CARL GUTHRIE j 45 Ibid., Test Number 150.
46 Ibid., Test Numbers 7, 6.
47 Guthrie 2/12/85, pp. 72-73, 75, 76. l l
48 Vol. III, Table 4.
49 Vol. IV (MPR Report) Appendix K, Test Numbers 8, 7, 6, 5, 2. I i
50 Ibid., Test Numbers 7, 2.
51 Guthrie 2/12/85, pp. 3, 9-10. l 53 Ibid., p. 6. i 53 Ibid., p. 12.
54 Vol. III, Tables 1 and 4. l 55 Vol. IV (MPR Report), Appendix K, ,
Test Number 150. !
56 Smith 2/8/85, pp. 81, 86-87; l Guthrie 2/12/85, pp. 34-36, 38. I 57 Ibid., Table 1.;
Vol. IV (MPR Report), Appendix K, Test Number 149.
58 Vol. III, Tables 2 and 4.
59 Vol. IV (MPR Report), Appendix K, Test Number 148.
60 Vol. III, Table 4.
61 Vol. IV (MPR Report), Appendix K, Test Number 147.
62 TMI-2 Daily Plant Status Report and Shift Supervisor Turnover Notes, October 18, 1978, (Tab 10).
63 Guthrie 2/12/85, pp. 43-44.
64 Ibid., p. 44.
65 Vol. IV (MPR Report),Section III; l
McGovern 2/6/85, pp.90-107 CARL GUTHRIE 66 Vol. III, Table 4.
67 Ibid., Table 1; Vol. IV (MPR Report), Appendix K, Test Number 5.
68 Guthrie 2/12/85, p. 23.
69 Vol. III, Table 4, (March 15-28, 1979).
70 Ibid.
71 Guthrie 2/12/85, pp. 19, 30-31, 65-66 72 Guthrie 2/12/85, p. 29.
73 Ibid., pp. 31-32.
74 Ibid., pp. 32-33.
75 Ibid., pp. 32-33.
76 Ibid., pp. 27, 33.
77 Ibid., p. 33.
78 Smith 2/8/85, pp. 56-57.
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