ML20238F524
| ML20238F524 | |
| Person / Time | |
|---|---|
| Site: | Indian Point  |
| Issue date: | 05/06/1998 |
| From: | NRC |
| To: | |
| Shared Package | |
| ML20238F518 | List: |
| References | |
| FOIA-98-261 NUDOCS 9809030427 | |
| Download: ML20238F524 (75) | |
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I UNITED STATES NUCLEAR REGULATORY COMMISSION REGION 1 In re: CON EDISON, INDIAN POINT An Enforcement Conference was held before Loretta B. Devery, Registered Professional Reporter and Notary Public, at the offices of the United States Nuclear Regulatory Commission, Region 1, 475 Allendale Road, King of Prussia, l
Pennsylvania, on Wednesday, May 6, 1998, commencing at 12:55 P.M.
j PRESENT FROM NRC: PRESENT FROM LICENSEE:
l HUBERT MILLER PAUL KINKEL CHARLES W. HEHL GEORGE HUTCHERSON WILLIAM AXELSON VIC MULLIN LARRY NICHOLSON ROBERT ALLEN JOHN ROGGE CHARLES JACKSON SINGH BAJWA FRANK INZIRILLO ROBERT TEMPS HARLAN SAGER RICHARD BARKLEY A. RANDOLPH BLOUGH TRACY WALKER i J. BRADLEY FEWELL, ESQ.
'1 ALL POINTS REPORTING I 723 Erlen Road q 4
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Norristown, PA 19401 7 (610) 272-6731 ,
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ALL POINTS REPORTING (610) 272-6731 !
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I 2' bUt. ROGGE: I think we're ready to 3 recommence-for the closed session of the enforcement 4 conference. And there have been some-players that 5 have changed. Most of us know each other, but let's
.6 go.back through introductions again.
7 I'm once again John Rogge, Branch i
8 Chief.
9 MR. BAJWA: Singh Bajwa, NRC.
10 MR. AXELSON: Bill Axelson, Deputy 11 Regional Administrator.
12 MR. MILLER: Hub Miller, Regional 13 Administrator.
]
14 MR. HEHL: Bill Hehl, Director of
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15 Division of Reactor Projects.
16 MR. TEMPS: Rob Temps, Senior Resident l
17 Inspector. i 18 MR. BARKLEY: Rich Barkley, Project i 19 Manager, Branch 2.
20 MR. HUTCHERSON: George Hutcherson, 21 Chief Engineer.
22 MR. MULLIN: Vic Mullin, Manager, 23 Coned.
-t Paul'Kinkel, VP, Coned.
24 MR. KINKEL:
ALL POINTS REPORTING (610) 272-6731
~
. ~
3 i
! 1. MR. SAGER: Harlan Sager, Manager of 2 Quality Assurance Programs.
3 MR. JACKSON: Charlie Jackson, Coned 4 Manager, Nuclear Safety and Licensing.
5 MR. ALLEN: . Bob' Allen, Coned Licensing.
6 MR. INZIRILLO: Frank Inzirillo~,
7 Manager of Coned Test Performance.
8 MR. ROGGE: The reason we're here today 9 is to discuss with you an issue that occurred 10 regarding your Appendix R battery lights. This 11 issue first came to our attention on August 18th 12 when our NRC resident inspectcrs identified that two I
13 of three battery cells had low water level. They
, 14 then asked'for a copy basically of your August 8th
.15 monthly check and saw that it was satisfactory.
16 They then selected another 12 samples 17 and identified two more deficiencies noted.
18 Basically one cell was-about 50 percent level, and 19 the other one had two of its three cells low.
20 The residents inquired of you asking l
L 21 why there is a low level, is there a test procedure
-22 or a performance problem. You then launched an 23" investigation to determine what had gone on.
24 Basically our understanding is the test at that ALL POINTS REPORTING (610) 272-6731
4 g .1 point'was determined to be done in about 15 minutes.
2 However, reasonable estimates would indicate about
-3 one to three hours be required to do it.
4 Our NRC Office of Investigations 5 conducted an investigation to determine whether 6 deliberate wrongdoing had occurred. And they 7 determined that deliberate falsification had 8 occurred by a nuclear product'.;n technician. In the 9 letter that we sent to you, we informed you of the 10 results of this investigation in a February 25th, 11 1998 letter, and we asked that you would be 12 addressing basically these four items and some more i
13 I'll go into, but the apparent falsification of the 14 emergency lights appears to have been --
I lost my 15 slides that I was reading. But we were concerned 16 with the magnitude of the falsification plus the --
17 and a second independent check that was done on 18 diesel gene rator surveillance.
19 Now, this individual was also helped by 20 another individual on the first. Also the report 21 indicates that the test had been inadequately 22 performed on multiple previous occasions.
23 Basically, the procedure details various steps that 24 have to be done. Apparently, for a long period of u
h _ALL POINTS REPORTING (610) 272-6731 t
5 i
i time, they had converted over to some short form of l
2 testing, basically using a stick and making rapid 3 determinations.
4 As a result of that, there was 5 detrimental impact on the equipment, as was l 6 identified in the field -- and I'm drawing a blank.
! 7 The likely involvement of another technician beyond l 8 the individual noted in the OI synopsis.
9 Now, since there were two individuals, 10 one of the individuals that was helping Mr. Vincent 11 was the person who has like performed this 12 procedure, but he apparently was not qualified at 13 the time for that side of the building. So he is 14 also implicated here, but he's not coming in 15 directly that he was the deliberate falsifier.
16 I want to recap. So once again, we've 17 come to the conclusion that there's'a strong 18 likelihood that he'd been doing this for five to six 19 years. It goes to an informal attitude with respect 20 to procedural adherence which developed among the 21 nuclear production technicians which may have been 22 tacitly fostered by your own management.
23 Qualifications for these individuals 24 apparently are not maintained. That is partly why e
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6 I 1 it's very.hard to tell who was qualified to do what.
l 2 And that you didn't have an adequate training 3 program for this group.
4' All these things were highlighted to 5 you in the letter and basically are in essence 6 coming out of that OI report that we need to talk l 7- about today.
8 So.the purpose, like I mentioned in the 9 first meeting, is once again for us to come to a 10 common understanding of the facts, the root causes, 11 any missed opportunities to identify, we need those 12 explained, corrective actions, significance of the
.f:
13 issues, and a need for lasting and effective L
14 corrective actions.
15 And also probably Charlie will provide l
l 16 the severity of the violation = as you see it and the L 17 credit that you think you should deserve and any i 18- other applications under the enforcement policy.
l- 19 In the letter that we sent you and the 20 apparene. violations that we need to discuss 21 specifically are your failure to complete accurate 22 information as required by 10 CFR 50.9 and failure 23 to comply with the overall license condition, which 24 basically governs the maintenance and the controls ALL POINTS REPORTING (610) 272-6731
7
- 1 of that NRC Appendix R fire protection regarding 2 monthly lighting checks.
3 Any questions?
4 MR. HEHL: Let me just add that as 2
5 you're aware, we're going to hold a conference with 6 the individual involved from the standpoint of that 7 individual's culpability in these matters, but part 8 of what we need to determine certainly, and we 9 normally do hold licensees accountable or 10 responsible for the performance of the employees, 11 and as we indicated both in the letter and in John's 12 slides, you know, we view this as part of a broader i
13 problem which certainly we'd like to have you 14 address as we go through.
15 MR. JACKSON: We've arranged this 16 afternoon's presentation in the following order:
17 We'll talk about the specifics of the two apparent 18 violations of 50.9. And we notified you in 19 accordance with 50.9 on October 8th, at the 20 conclusion of our investigation, but we've been 21 keeping the residents informed prior to that. We'll l 22 discuss-the special investigation which was i
f 23 conducted by our Quality Assurance Department, go i
24 through the things they looked at and findings they ALL POINTS REPORTING (610) 272-6731
8
, 1 came up with.
2 We'll discuss specifics for the test 3 group for the procedural adherence, supervisory 4 oversight, and do some conclusions. But there were 5 a couple of other other questions in the letter 6 which we'll address regarding qualification and 7 training of the technicians and some things that 8 we're go - to be doing.
9 At this point, I'd like to introduce 10 Frank Inzirillo who will start off with the 11 violations.
12 MR. INZIRILLO: Good afternoon. As has
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13 been mentioned, we're here to discuss the events 14 which we notified you of on October 8th, 1997, which 15 resulted in the suspension of two ConEdison 16 employees and the subsequent termination of one of 17 those two.
18 Those violations consisted of 19 surveillance test of Appendix R emergency lights and 20 also a weekly surveillance test on the emergency 21 diesel generators. In the case of the emergency 22 light test, the review of records indicated that the 23 individuals had not spent a sufficient amount of I
24 time in the primary auxiliary building to adequately l
I ALL POINTS REPORTING (610) 272-6731
9
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i i complete the performance of the emergency light 2 test. Those two technicians were suspended for one 3 month each, 4 In the second case, one of the two 5 technicians had failed to perform a double 6 verification that he had signed for on a weekly 7 inspection of the emergency diesel generators in the 8 case of double verifying the position of the switch 9 in the final as left position of a valve. As a 10 result of that, that particular technician's 11 employment was terminated.
12 I'd like to introduce Mr. Harlan Sager o
13 of our Quality Assurance Department, who will 14 discuss the review he had conducted of station 15 surveillance activities as a result of the events.
16 MR. SAGER: The Quality Assurance 17 Department conducted interviews and prepared reports 18 relating to the identification of the inaccurate 19 record of test results. Collectively a hundred 85 20 surveillance tests were reviewed. No problems other 21 than the two inaccurate records which have been 22 identified here were uncovered as a result of that 23 review.
24 There were, however, a number of
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l ALL POINTS REPORTING (610) 272-6731
10 1
recommendations which were made. These reports 2 assessed first the potential for tests to be 4 3 performed where the data could be recorded without
)
4 actually performing the test. So we looked at those 5
tests which had the highest probability of t' hat I 6 occurring. We conducted a review of all the 7
emergency light tests from July of 1996 through 8 September of 1997. And we looked then at ways of 9 finding other corroborating evidence to substantiate 10 that these tests are actually being performed in the 11 field, and not only by this group, but we're also 12 looking at additional groups.
13 Interviews were conducted by the 14 testing --
of the testing performance manager, and 15 also by the testing performance manager of the test 16 supervisors, of control room operators, and of one 17 test technician. The information obtained was used I 18 to support or refute the observations made from the l
19 reviews of these test results.
- 20 Extensive documentation was reviewed as 21 part of this effort. This included the test 22 procedure records themselves, the control room logs,
~23 the key control logs, the locked valve control 24 sheets, the measuring and test equipment usage ALL POINTS REPORTING (610) 272-6731
11 I 1 records, and the security access records. For the 2 review of tests which had the potential to be 3 recorded without actually performing the test, a 4 i total of 65 test procedures were looked at other 1
5 than those for emergency lights. These covered six 6 distinct tests that did not involve interactions 7 with other groups and thus are considered 1
8 susceptible to recording data without actually 9 having performed all the requirements of the test.
10 These tests were performed from 11 December 1976 through September of 1997. It was 12 from this review that the emergency diesel weekly i
13 test procedure, the data from this review was being j 14 looked at in which the testing performance manager 15 identified this other example which is part of this 16 discussion. The performance of all of the other 17 tests was reported -- that were recorded was 18 supported by the evidence from this review.
i 19 MR. MILLER: Let me just make sure I '
3 20 understand. You looked at all or some samplings of l 21 the tests that are periodic, repetitive kind of 22 tests or tasks, surveillance, whatever you want to
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23 call it beyond what's done for these emergency I
24 lights, but short of things that are done by i
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12 i 1 multiple parties. Did you check all or just a 2 sample?
3 MR. SAGER: It was a sample of those, 4 but it was specifically those six tests which had 5 the highest likelihood of giving an individual the 6 opportunity to do that because they involved the 7 least interaction with other groups. So this was 8 not all test results. That was the first area that 9 the reviews were conducted.
10 There were two other reviews that were 11 completed.
12 MR. AXELSON: Did the AO logs fall into i
13 that criteria you just mentioned?
14 MR. SAGER: The control room logs?
15 MR. AXELSON: No, no, the field logs, 16 the logs by the non-licensed operators in the field
- f. 17 every eight hours.
18 MR, SAGER: No.
19 MR. AXELSON: Why wouldn't that meet l
20 your criteria that you just discussed?
L 21 MR. SAGER: These were the specific I
22 surveillance test procedures --
i 23 MR. AXELSON: No surveillance --
i 24 MR. SAGER: -- performed by the test l
l ALL POINTS REPORTING (610) 272-6731
13 4 1 group, not by the NPOs in terms of those daily logs 2 that we were.looking at in this group.
- 3. MR. AXELSON: Why would you just kind 4 of narrowly chop it to that area? Why wouldn't you 5 expand ic to that organization which is frequently 6 looking at repetitive --
7 MR. SAGER: The focus --
8 MR. AXELSON: --
observations?
9 MR. SAGER: The focus of this 10 particular review was on those tests for which the 11 test technicians performed those tests, not those
' 12 that are performed by the operators.
f 13 In other words, if you look at all the 14 tests that are being done, there are different 15 groups that perform them, okay. So this review 16 focused on just that group.
17 MR. BAJWA: Did you also review the l
18 test procedures itself and their validity?
l )
1 19 MR. SAGER: What we reviewed was the 20 test procedures and the correlation of was the
'21 person where he had to be to record that 22 information. The kinds of information that you're 23 looking for in this particular review to record its 24 validity would be, you know, what's the level of the ALL POINTS REPORTING (610) 272-6731
( -- - - - - . - - - - - - - _ - - - _ - - - - - - -
14 g 1 acid in the battery and the type of things like 2 that.
3 So the only thing that they looked at 4
was was it consistent from test to test or was there 5- a trend, did it vary with temperatures. You'd 6 expect it to, but it was not really easy to say was 7 there some other data sheet which had that same 8 value that you could compare it with.
9 MR. BAJWA: I understand that, but the 10 tests itself, how did you measure the battery acid?
11 MR. INZIRILLO: The review showed us 12 that there was some areas in the test that needed i
13 improvement. For instance, the test permitted for a 14 technician to check the water level, and as long as 15 the water level was between the minimum and the 16 maximum mark that was set. And apparently what on 17 some instances occurred, as long as it was barely 18 above the minimum mark, it was left that way and L
19 then time allowed it to drift below. We were able l
! 20 to see that when we went back with some batteries 21 that we had later done some maintenance on and 22 replacements of, we saw that some were --
some 23 batteries had an unusual usage rate because we i
24 identified them to be low, we refilled them, and ALL POINTS REPORTING (610) 272-6731
= .
15 4 1 they were found low a week or so later on a 2 reinspection.
3 So we identified the fact that the test 4 allowed the technician to walk away from the battery 5 with the water low at the minimum mark was not the 6 best way to do that test. We changed the criteria 7 in the test to say that the water level had to be 8 halfway between the minimum and the maximum. And if 9 it wasn't, then add water. So we've changed that.
10 That is an enhancement that we wanted to make in the 11 procedures as a result of recognizing that that was 12 questionable.
I 13 Also, we identified that the acceptance 14 criteria in the emergency light test did not include 15 the inspection of the battery terminals. Although 16 that was in the body of the test, it did not -- it 17 was not identified as acceptance criteria. So we 18 added that as acceptance criteria to the test. And 19 there was a root cause analysis report separate from 20 what Harlan had done that took a broad based look at 21 the emergency lights. And out of there came some l 22 recommendations that would cause us to enhance the l
23 content of that test.
i 24 MR. SAGER: As a result of each of ALL POINTS REPORTING (610) 272-6731
16 1 these reviews, there were a number of 2 recommendations as to what we needed to do to 3 strengthen this area and this program. And I think 4 Frank's going to cover those in much more detail.
5 The second category was the Appendix R that we 6 looked at.
7 MR. HEHL: Before we leave the testing, 8 you mentioned a number of a hundred 80 tests in the 9 very beginning of your discussion.
10 MR. SAGER: A hundred 85 surveillance 11 tests.
12 MR. HEHL: There was a hundred 85 1
1.3 surveillance tests, that was the scope of the 14 review?
15 MR. SAGER: That was the total of the 4
16 three independent reviews of, which I've talked so
! 17 far about the first review, 18 MR. HEHL: Okay. And the first review 19 included the 65 tests, of which then a sample of i
( 20 six, six of the 65.
l 21 MR. SAGER: No, the first review r
22 included 65 total tests were looked at. Those were 23 six distinct tests, the same test was performed 24 multiple times.
ALL POINTS REPORTING (610) 272-6731
l 17 g 1- MR. HEHL: I got i t ,. okay.
l l 2 MR. SAGER: But those were identified 3 as those most likely to be performed without 4 interaction of other groups.
5 MR. ROGGE: And your goal was to look l
6 for what other instances where people were not doing 7 their --
(
8 MR. SAGER: That is correct, were there i
9 other instances which looked like people were not 10 performing the test like they were supposed to be 11 performed.
12 The second review, as I started to say, i
13 is the Appendix R test lights specifically. And 14 this' covered the period of July '96 through August 15 of '97. These reviews established that multiple 16 technicians did have sufficient time in the area to 17 perform those tests. However, if they were 18 performing it exactly like the procedure, it did 19 raise a number of questions whether or not they were
-20 actually following exactly all the details of the i
21 procedure, and that was clear.
22 Then the third review what we did is we 23 took the over 600 different distinct surveillance 24 test procedures and we segregated those by the ALL POINTS REPORTING (610) 272-6731 L---_------------_---__---------.---_----------------- - - - - - - - = - - - - - - _ - - - - - - - - - - - - _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
18 i i different groups which performed those tests. And 2 then from that, we categorized those as to what ways 3 can I determine other objective evidence to support 4 that this test is being performed or specifically 5 identify other objective evidence that would prove 6 it could not have been performed.
7 So we looked at a sample of those 8 tests. We specifically chose 450 tests that were 9 performed by the test technician group, and we 10 looked at a sampling of 100 tests. Out of that 11 group, in each of these three different categories, 12 the total sample population was one hundred. It i
13 varied by which was in each group. And again 14 attempted to determine were there any circumstances 15 which the test could not have been performed, or was 16 there enough objective evidence to be looking at the 17 correlation between entries in the central control 18 room logs, the key control logs, the measuring of 19 test equipment usage, or the secure access logs that 20 the people were where they were supposed to be and 21 performing the steps that were required.
22 Again, most of these tests do not lend 23 themselves to taking a value and comparing it to e
24 something else very easily. And again, this ALL POINTS REPORTING (610) 272-6731 t
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1 ' evidence.did not find anything which allowed us to 2 determine that these tests,were not being performed.
3 Again, we made several recommendations ae a result of that review.
5 MR. ROGGE: Are you saying that was a 6 success or that it was just indeterminate?
7 MR. SAGER: I'm'saying that it was a a success. There was one test in which we could not 9 find any'way of substantiating, other than the test L 10 data, that the test was performed. So that was the 11 synopsis of the sample that we reviewed of these
(.
( 12 particular tests related to this test group.
!I 13 In addition, we put together a. plan to.
14 periodically review other groups besides the test l 15 technician groups to assure that they're performing 16 these tests as we expect them to. We looked at the 17 work order history, we also looked at the open item 18 reports to see if there was a correlation between L 19 the actual writing, the corrective maintenance work i
! 20 orders, where discrepancies were found in the test 21 or nonconformance reports. And those supported this 22 also.
23 In addition, we looked at all of the
'24 work orders for corrective maintenance that were ALL POINTS REPORTING (610) 272-6731
20
. I written on all the emergency lights that are in the 2 operating equipment database, and that covered the 3 years 1988 through 1997. For 1988 through 1996, 4 there's a fairly consistent number of these that are 5 identified each year. However, as a result of a 6 number of changes that were made to the test, which 7
Frank talked about earlier and we'll talk about 8
more, and after the increased emphasis on recording 9
the information so that we have a better record of
\
10 it, in the last quarter of '97, t'he number of those 11 work orders did increase. But as far as the past i
12 history before this event, we saw it was relatively 13 consistent in terms of the identificativu of 14 problems with these lights from '88 through '96.
15 Frank also mentioned that there was a 16 root cause investigation that was performed by the 17 fire protection system engineer. And a number of 18 recommendations were also made from that review. So 19 I would like to turn it back over to Frank who will 20 address the continuing efforts and the 21 recommendations of how we're handling those.
22 MR. INZIRILLO: That root cause 23 evaluation that Harlan mentioned did go on to 24 conclude that there were no increased events of ALL POINTS REPORTING (610) 272-6731
21 l i 1 inoperability of emergency lights as a result of the o
2 fact that he had mentioned the increased work 3 orders. Most of those led -- were the result of the 4 fact that the acceptance criteria was changed to 5 include the terminal battery terminal inspections.
6 And those started to show up then as questionable 7 and work orders were written for those, but none of 8 them adversely impacted the operability of the 9 lights as had been determined by that evaluator.
10 MR. ROGGE: I thought you were always 11 required to look at the terminal.
12 MR. INZIRILLO: The procedure had a i
13 terminal inspection and also steps for cleaning the 14 terminals if anything was found on them, but it did 15 not include them in the acceptance criteria. So if 16 any discoloration was identified on terminals, that 17 was not a test failure. The procedure was changed 18 to include that as acceptance criteria as a result 19 of some reviews of requirements of the test as well 20 as reviews with the Appendix R system engineer for 21 what should be a required acceptance criteria in the 22 test.
23 MR. ROGGE: When you looked at the work i
24 orders before and after, did you see the same i
ALL POINTS REPORTING (610) 272-6731 l
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22 1 character of type of deficiencies being identified, 2 or were they consistent with what you find with just 3 the stick test, that they battery drops out and you 4 do major maintenance?
5 MR. SAGER: After we changed the 6 procedures, we saw a lot more work orders being 7 written for erosion of battery terminals at low 8 level than we saw exactly --
9 MS. WALKER: When actually were the 10 procedures changed?
11 MR. INZIRILLO: The number of the 12 procedure?
13 MS. WALKER: When were the procedures 14 changed?
15 MR. SAGER: The procedure revised for 16 the acceptance criteria?
17 MR. INZIRILLO: November time frame.
18 MS. WALKER: November '97, so it was 19 after.
20 MR. INZIRILLO: After this event, 21 that's correct. It was after this event. I l
22 MR. HEHL: Are you going to go through.
l 23 the root causes that you identified? These appear 24 to be the corrective actions.
ALL POINTS REPORTING (610) 272-6731
23 I 1 MR. INZIRILLO: Yes, we'll discuss what 2 we found in the performance of those two
- 3. investigations. Also some reference has been made 4 to'the stick test. And just if'I-could address
. S' that, what we had found is that there were some-l-
6 inconsistencies in the way'this test was performed 7 among the technicians. Two of the test technicians, 8 the ones that we're discussing today, had 9 gotten -- developed a practice of using an 10 . extension device, a stick, to reach those lights
'11 that were not easily reached without some other 12 assistance.
(
13 In doing so, they were capable of 14- inspecting those aspects of the lights that needed
'15 to be inspected from the position they were at. The 16 one thing they could not do, obviously if they 17 couldn't reach it, is open up the case and inspect 18 the terminals. We had done some field checks to 19 verify whether or not it was physically capable to 20 go around and inspect the lights in the PAB and 21 check those attributes absent the terminal 22 inspection, given the period of time that they were
- 23 in there, without trying to speed race around the
'I' 24 primary auxiliary building. And it was capable to ALL POINTS REPORTING (610) 272-6731
24 1 get around.
2 As a matter of fact, one person, I did 3 it personally, could go around to each light, check 4 all the attributes, within that time period. Now, I 5 don't want to give anybody the indication that I'm 6 suggesting that is adequate, but re're trying to 7 determine, based on the interviews that we had with 8 the technicians is what they were saying feasible, 9 was there any level of credibility in the statements 10 that they had made to us, even though in the end 11 there was no doubt that the performance was 12 inadequate.
I 13 So we attempted to at least validate 14 some aspect of that by going around to the lights.
15 MR. TEMPS: Can you reconcile for me, 16 we know that this informality of using the stick for 17 the elevated lights came into use. And there is a 18 block for each battery in the PTM 21 I think it is 19 that says that they've checked the battery 20 terminal --
terminals. Now, you've concluded that 21 as far as you can tell, August 8th is the only date 22 that this individual falsified records. But if 23 you've got this practice of using the pole for the i
24 remotes and you go to the procedures and they've ALL POINTS REPORTING (610) 272-6731
25 i signed for checking the battery terminal connections 2 for looseness, isn't that evidence that -- I mean 3- that's what we're saying, when we look at our 4 review, isn't that evidence that it goes beyond just 5 that one day or August 8th? Pretty strong evidence 6 I think.
7 MR. INZIRILLO: Based on the interviews 8 that we had conducted, the one test technician, 9 Jerry Stipik, had said that he did everything he was 10 supposed to do. That that was basically his 11 statement based on the interviews. The other 12 technician that was assisting him that day, who was t
13 Robert Vincent, had at first stated that he didn't 14 necessarily recall all the events of that day, but 15 said that if he was only in there for 15 minutes, 16 obviously he couldn't do everything that the 17 procedure required.
18 Later, additional questioning of Mr.
19 Vincent caused him to make the statement that it was 20 his opinion or impression that if the lights were l
l 21 working adequately, then the terminals must have 6
22 been okay. That was a statement he had made. And 23 he admitted to the fact that the inspection of the i
24 terminals was not something he had done routinely.
ALL POINTS REPORTING (610) 272-6731
26 I 1 Mr. Stipik never admitted to the fact 2 that there was any aspect of the conduct of the test 3 that he had done incorrectly. Those were the facts 4 of the interviews that I conducted. And the other 5 two test technicians that performed these tests both 6 stated that they did inspect the terminals in some 7 cases by opening the covers and in other cases by 8 using a flashlight. And on some of the cases 9 there's a little hole on the side or you can look 10 through the back and you are capable of looking at 11 the terminals without opening the casing. So the 12 interviews came to that determination.
I 13 And we were able, obviously what we did 14 conclude as a result of that August 8th inspection 15 was that clearly terminal inspections did not occur 16 on that day. When we went back and we looked at a 17 full year's worth of tests, both in the emergency 18 light test and the other test that was in question, 19 the diesel test, we did not see any repeat of the l
20 behaviors of that day based strictly on looking at 21 security logs and timing. We didn't see any other l 22 times when we looked at the emergency diesel test 23 that someone failed to go in during the times that i
24 the diesel test was being performed.
ALL POINTS REPORTING (610) 272-6731 u-- - - - - _ - - - - - - - - _ _ - - - - - - - - - - _ - --
27
) 1 We didn't see any other instances of 2 15-minute inspections, and that's what we asked --
3 we had done that. I looked at them personally, I 4 asked my test supervisor to look at them personally.
5 I asked QA to do an independent investigation'n to 6 ensure that in fact what we found was not something 7 that we were missing along the line.
8 When we went back and looked at this 9 day, there was something about this day that was 10 different than any other time that those tests had 11 been performed.
12 MR. TEMPS: I would argue that if the 13 test was done correctly, based on when you looked at l
14 the records, that there was sufficient time to do 15 the tests, then why would you even need the stick 16 method if the test was being done correctly, if they 17 were getting up on a ladder?
18 MR. INZIRILLO: There were some 19 examples. On one occasion I had run --
while in the 20 field, I had stopped to talk to some technicians who 21 were doing an emergency light test at one time and 22 they were waiting for maintenance to come up with an 23 up-up, which is a portable device to lift them up 24 into the air to get to the light. So what they had ALL POINTS REPORTING (610) 272-6731
l 28 l : 1 done in that particular -- in that particular case 2 was that they had gone ahead with those portions of 3 the test that they could do as far as the visual ;
4 inspection, the water level, the energizing the ;
I 5 light, and that would be the only time that at least !
6 those technicians had, other than the two we're 7 talking about here, had used a stick was to check 8 the energization of the light, to do all of that, 9 and then had moved on waiting for maintenance to 10 come with the up-up so they could get back to those l
11 lights and do the terminal inspection.
12 MR. MILLER: Do you have some records, l
13 whatever you call this portable scaffold being 14 brought out to these locations even on a sample 15 basis, this is what they said and --
16 MR. SAGER: I attempted to do that 17 correlation on some of them that I looked at, and I 18 could not produce the actual issuance of this tool i 19 to them.
1 20 MR. INZIRILLO: It doesn't get issued, 21 the maintenance provides it on request.
22 MR. SAGER: Right. And so they provide 23 generally a person who operates it. So I can't 24 correlate that that person did in fact operate it ALL POINTS REPORTING (610) 272-6731
29 1 that day for that test. Or also there were two 2 other things that caused a problem here. One was 3 that these tests were frequently being done over a 4 span of several days. And secondly, that every 5 individual 'vho may have done some portion of the 6 test was not signing for each of those te;ts that 7 they did. Only one individual signed.
8 So as a result of that, when you 9 started looking at who all were the individuals who 10 did this test, what you had is one person said I 11 completed the test, but more than one person may 12 have actually checked some of these aspects of it.
13 So it was, when you added all that together and 14 their times, that there was sufficient time for them 15 to have done all of the activities. We could not 16 determine looking back that they did in fact do 17 everything, but there was sufficient access for 18 that.
19 MS. WALKER: I have two questions.
20 One, when you say, you know, multiple individuals, 21 does the actual test have individuals sign-offs for 22 each light?
23 MR. INZIRILLO: No, it does not.
24 MS. WALKER: So you can't tell like ALL POINTS REPORTING (610) 272-6731
30 I 1 this person did five, you can't recreate that?
-2 MR. INZIRILLO: That's correct.
3 MS. WALKER: What did you determine was 4 sufficient time to do the test?
5 MR. INZIRILLO: I had an individual go 6 out and came back and said that three minutes per 7 light would be adequate to take -- to get to the 8 light and do all the different pieces of the test as 9 identified.
10 MR. BAJWA: The two interviews 7
11 determined whether only people who did those tests, 12 that they understood what they're expected to do, t
13 expectations were well-known to them?
14 MR. INZIRILLO: Yes.
15 MR. HEHL: Well that gets to the root 16 cause I guess.
17 MR. INZIRILLO: I think in the case 18 of -- in the' case of Mr. Stipik, there's some things 19 that remain undetermined. What he actually did that 20 day and what was on his mind, I can't speak +.o. I J
21 can speak to the answers to the' questions that ne l 22 provided us when we interviewed him. He did not l
23 admit outwardly that he had misperformed that test.
24 In the case of Mr. Vincent and the l
I ALL POINTS REPORTING (610) 272-6731
31 i 1 results of his interviews, they varied a little bit 2 as far as the answers go, but'in essence he did at 3 one point in time admit to the fact that if that's 4 the amount of time he was in the building, he can't 5 see how he did the test adequately, but he didn't 5 have adequate recollection of what occurred that day 7 and what exactly he did.
8 He was not the primary signer of the 9 test. He was assisting Mr. Stipik that day who had 10 responsibility for the test that day. The 11 emergency -- the emergency diesel double 12 verification issue was on the same day, by that same i
13 individual. And again, in the interviews with him, 14 he does --
he doesn't speak English clearly, he 15 speaks a little bit of a broken English, difficult 16 at times to understand exactly what he was scying.
17 So at times I would repeat back to him what I 18 thought he might have said to ensure that I had a 19 clear understanding of the intent of his statements.
20 But at no time did he admit to misperformance on 21 either one of those two tests.
l l 22 The evidence on the emergency diesel 23 generator double verification event was pretty 24 straightforward. He had to enter that building to ALL POINTS REPORTING (610) 272-6731
32 I 1 do those double verifications. He in fact had 2 signed for them, no one had been in the building 3 during the period of time at which the double 4 verifications were to have been performed. That was 5 pretty clear and open and shut as far as tha't goes.
6 We went back and looked, as I said before, previous 7 years of those and found no similar instances either 8 of him or anyone else where someone failed to enter 9 an area where they had signed for something.
10 MR. MILLER: Okay.
11 MR. INZIRILLO: So in looking at the 12 emergency light tests and identifying the i
13 inconsistencies, we improved the procedure. We made 14 it clear to the technicians what the expectations 15 were, including the fact that inspecting the 16 terminals through access ports or with a flashlight j i
17 in addition was not acceptable, that the terminal l 18 inspection was asked to be done, that you open up 19 the battery case and you do that inspection.
20 We further enhanced that procedure to 21 state where now we use a DVM as opposed to even 22 looking at the indicating meter on the face of the 23 battery pack. So that there's a need to open that 24 up and actually hook up a meter to identify the
< ALL POINTS REPORTING (610) 272-6731 1
l-33 4
l -' t i voltage on the light subsequent to the energization.
p 2 The other issue that we identified was L
3 the 60 to 90 sec7nds on the light. The test says to 4 energize the light for approximately 60 to 90 5 . seconds and then take the voltage reading. ' Wha t we 6 determined from our interviews is that, one, that no l 7 one was timing that 60 to 90 seconds. What they 8 were doing was a subjective assessment. What would 9 happen is you would push the test button on the 10 light, the light would come on, the voltage 11 indicator fields would come down to a new value and 12 it would stay there and pretty much regardless of i 13 how much -- how long you held it.
14 I checked with the system engineer on
'15 the system to determine if that was the typical 1
16 response of that type of battery, and in fact it j j
17 was. The drop in voltage you're-going to see you're l 18' . going to see right away and any further degradation b 19 would occur over a much longer period of time. What 20 they had been doing or what they got themselves to 21 believe was-that-that's the voltago that we want on 22- this test. So they push the button, they watch the 23 voltage'come down, they looked at it as long as it 24 was steady, they recorded that value. So there was ALL POINTS REPORTING (610) 272-6731
34 4
1 1 no physical start and stopwatch 60 seconds later 2 record the value. So there was a lack of 3 appreciation of that 60 to 90 seconds.
4 Whether it was technically required to ;
5 hold it there that long or not is somewhat 6 irrelevant. The procedure calis for it, they're 7 required to do it. So we discussed a number of 8 those issues with the tests with the expectation of 9 the wording of the test. Regardless of what they 10 may learn about how the equipment operates over 11 doing it for such a period of time, that's not the 12 expectation. The expectation is you do what's in i
l 13 the test. If you have a question about in or you l
14 have a better way to do it, then please prcvide that 15 so that we can make improvements as the case may be.
l 16 So we addressed a number of those 8
l 17 issues. As I said, we addressed it in the test and l
18 with discussions with the technicians and what the 19 expectations are.
l 20 And in the area of expectations for job 21 performance and especially procedural adherence, 22 those issues have been communicated to the 23 technicians on numerous occasions during various t
24 group meetings and breakfast meetings, we would have t
ALL POINTS REPORTING (610) 272-6731
j 35 l
i 1 discussions on the importance of their job 2 performance, specifically procedural adherence.
3 In addition, there had been discussions 4
about the importance of an individual signature and 5 what that_ meant when you sign a document, and also 6 recognition of the fact that because of the nature
(
'4" 7 of the tests that they would do that they were j 8 relied upon to perform these tests without a 9 continuous supervisory oversight when they were 10 doing these tests or inspections in the field.
11 {
MS. WALKER: Frank, these discussions l 12 that you're talking about, was that since this i
13 event?
14 MR. INZIRILLO: No, it was prior to the 15 event, prior to these events, there had been 16 numerous discussions about procedural adherence and 17 what the expectation was of that.
39 MR. MILLER: What are you trying to say 19 in that second bullet there?
20 MR. INZIRILLO: The fact that they were 21 being relied upon to perform their job without 22 someone standing over them continuously and that 23 there was an expectation of their job performance i i 24 that it was done properly, and that because of the ALL POINTS REPORTING (610) 272-6731
1 1
36
{
1 nature of it and because of the numerous inspections t 2 and because they tend to span the plant, you can't 3 have a supervisor following them around everywhere 4 they go.
5 MR. MILLER: I understand that now 6 that's what you tell them, but what's your own take 7 on it? You're saying that you told people ahead of 8 time, you say you reinforced that this is your job, 9 your job is to follow the procedures, is this --
do 10 you have any other conclusion to draw looking back 11 on this?
12 MR. HEHL: That's where we get to root t
13 causes from your two bullets up there. You can -- I 14 guess you can imply that one of the root causes was 15 a miscommunication of procedure adherence 16 requirements, you know, in the first one and perhaps 17 signature on the'second one. I guess I'm interested 18 in what explicitly were the results of your root 19 cause analysis and how do those correlate to those 20 that you describe?
21 MR. INZIRILLO: Although we 22 communicated the expectations, we did not take 23 advantage of the opportunity for adequate management 24 and supervisory oversight.
l l
ALL POINTS REPORTING (610) 272-6731 u___--___-_-__-
37
- 1 MR. MILLER: That's the point.
l 2 MR. INZIRILLO: Communication is only 3 part of how you accomplish or get that result.
4 First you tell them and then you've got to go make
! 5 sure that they're doing it and hold them accountable 6 for what they're doing.
7- MR. HEHL: So lack of supervisory 8 oversight was one of the root causes?
9 MR. INZIRILLO: That's correct.
10 MR. AXELSON: How was this event 11 communicated to the staff, this particular event 12 communicated,-the expectations, prior to this event?
i 13 MR. INZIRILLO: Discussions with the 14 members of the --
15 MR. AXELSON: What's happened since 16 this event, how has this been communicated to the 17 staff?
18 MR..INZIRILLO: We've had additional 19 discussions about procedural compliance. And I'm 20 going to go on and discuss a little bit more of 21 that.
22 MR. AXELSON: Okay.
i I 23 MR. INZIRILLO: On the management l
24 level, we're continuing to work at improving the ALL POINTS REPORTING (610) 272-6731
38 l
1 oversight of the surveillance testing process, l
2 including field walking of procedure in the field to 3 ensure the adequacy of the direction of the 4 procedures. So that they are doable without 5 question.
6 Field observations of technicians, 7 attendance at technician training sessions so that 8 discussions of any questions in the content of the 9 procedures or what's expected of the technician in 10 performing the procedures is clearly put forth at 11 the training sessions.
12 Interviews with the technicians to l
13 e"nsure that there's a clear understanding of the 14 expectations. After this event, each technician was 15 interviewed to not only understand how they may have 16 been involved in an event of this nature, but also 17 to make sure that they clearly understood what was 18 expected of them.
19 MR. AXELSON: You mentioned attendance 20 at training sessions. Who attended?
21 MR. INZIRILLO: Me. I went, I attended 22 training sessions.
23 MR. AXELSON: Do first line supervisors 24 attend training sessions?
ALL POINTS REPORTING (610) 272-6731
39 i 1 MR. INZIRILLO: Yes. What we did was, 2 and something that we're going to discuss later on 3 about training, in order to enhance the training of 4 technicians, we had temporarily suspended their 5 performance of surveillance tests, the ones that 6 remained.
7 We embarked on a focused training 8 program to cover a number of issues that we felt 9 were germane to the surveillance testing process.
10 Myself and the test supervisors were present at 11 those sessions. They gave the opportunity to have a 12 number of open' discussions about what's expected for i
13 procedural compliance, what do you do when we have a 14 procedure that may lack some detail but anticipate 15 some level of knowledge on the part of the 16 individual, how do you proceed if you had -- if you 17 have a question about what a procedure step 18 requires. A number of issues, you know, we were 19 able to discuss is that it was clearly understood on 20 the part of the technicians that if they get to any 21 step in the procedure where it is not' clear as to 22 what to do or they have any question about what to 23 do, they're to stop, they're to immediately inforrt 24 their supervisor. Their supervisor can either give ALL POINTS REPORTING (610) 272-6731
40 l
l t 1 some direction, if he has the ability to do that, or 1
s 2 get a hold of me or request a temporary procedure 3 , change or whatever it is to resolve the issue. But 4 their first direction is to stop. And we've seen l 5 examples of that since the time that we've enhanced 6 their understanding that they will stop and ask
- 7. questions.
8 , We've made changes to procedures based 9 on their questioning attitude, that has been evident 10 to us. We've conducted some independent checks of 11 security records since this time to give us 12 additional assurance that the message is clearly 1
13 there as to what our expectation of their 14 performance is. I meet daily with the test 15 supervisor to review issues of pre-job planning, l
16 schedule adherence, pre-job briefs, procedural 17 technical issues, anything that may be coming up 18 over the course of the day as to why or why not a 19 particular surveillance test has proceeded on as we 20- anticipated or why they had to stop or what kind of 21 changes may need to be made.
i
-22 We're getting to the point now where 23 those changes are being requested before the test is 24 scheduled because we're doing -- we're becoming ALL POINTS REPORTING (610) 272-6731
41
- 1 better at reviewing tests well enough ahead of time, 2 both the test supervisor as well as the technicians, 3 taking a look at things ahead of time so that we're 4 better prepared to go do the test when the time 5 comes.
6 MR. HEHL: I guess dropping back then, 7
am I to understand that one of the causes for these '
B performance issues coming out of your evaluations I 9 were the inadequacy of communications as far as 10 expectations and standards?
11 MR. INZIRILLO: Correct.
12 MR. HEHL: Another potential root cause I
(
13 or cause was training and procedures, training of 14 the individuals as to how to conduct these i
15 activities and the quality of the procedures.
16 MR. INZIRILLO: In looking at the I l
17 training issue, we do not see that to be a cause of '
l 18 this event. The training issue is something that, 19 as a result of reviewing this event, we've 20 identified to be an area that we can enhance, and 21 we're doing that.
22 MR. HEHL: But you don't see that as a 23 cause for these performance issues?
24 MR. INZIRILLO: No.
ALL' POINTS REPORTING (610) 272-6731 l
i J
42 i
,1 MR. HEHL:
( Procedure inadequacy, is 2 that a cause?
l 3 MR. INZIRILLO: In this particular --
4 MR. HEHL: Not implementation of the 5 procedures, adequacy of the procedures.
6 MR. INZIRILLO: No.
7 MR. HEHL: And then certainly i
8 implementation of the procedure, which goes along 1
9 with the communications of expectations. l 10 MR. INZIRILLO: Correct. j l
11 MR. HEHL: And then oversight of field 12 observations.
13 MR. INZIRILLO: Right.
14 MR. HEHL: So those are kind of root 15 causes for what you said.
{ 16 MR. INZIRILLO: As I said before, the l
l 17 thing that's unique about this particular event, 18 obviously in looking at this event, it opened our 19 eyes to other issues that we need to addrecs, but --
20 MR. HEHL: That's what we want you to 21 do.
22 MR. INZIRILLO: And we N.d that, and 23 that was good. I menn if anything, if we would even i
I
'4 suggest that anything comes out of an event of such ALL POINTS REPORTING (610) .272-6731
43 4 1 of this nature is that it causes us to look at other 2 things and improvements in other areas that maybe we 3 wouldn't have otherwise looked at.
4 But again, there was something unique 5 about this event that on that day, something 6 happened that was different that we did not see 7 examples of on any other day or any other test that 8 we looked at. So when we try to look at root cause, 9 it sometimes gets a little difficult to figure out 10 what happened with those tests on that day.
11 Now, if you want to look at those other 12 things in the broader view that we looked at and the
(
13 other things that we identified, definitely there 14 are areas where we need to make improvements and 15 we're going to make improvements. That's why I 16 find -- I'm not -- I can't one hundred percent say 17 that if all of those things had been in place that 18 event would have occurred on that day, and that's 19 the one thing that leaves me somewhat wanting as far 20 as really being able to understand that one day.
21 MR. HEHL: We're certainly not arguing 22 that the individual or individuals involved here i
23 certainly have performance issues. That's a given. l 24 I think that certainly is clear from our !
l ALL POINTS REPORTING (610) 272-6731 p
t _. _ __
l 44
- i. 1 investigative activities also.
2 The thing that we have to kind of deal 1
3 with also in addition to dealing with the 4 individuals' performance, which puts you in 5 violation of regulatory requirements, we also have 6 to understand, you know, what is your culpability as 7 a licensee in charge of providing oversight, 8 providing communications of expectations with regard.
9 to their performance.
10 And, you know, I think what I'm hearing 11 is that certainly these individuals had to perform 12 these acts and did them incorrectly and perhaps with
-(
13 some intent. But I guess in your reviews, you found 14 there were certainly some things that perhaps 15 contributed from the environment and the standards 16 that were set at the station in this area.
17 MR. INZIRILLO: That's correct.
18 MR. JACKSON: You keep asking root 19 cause of the event. I don't think ConEdison is 20 saying that we know the root cause of the event.
l 21 There are certainly performance issues which Frank 22 has been talking about.
23 MR. HEHL: Right.
24 MR. JACKSON: Why an individual --
ALL POINTS REPORTING (610) 272-6731
45
- 1 MR. HEHL: I'm not ~ trying to get you, 2 Charlie, to say what was in this guy's head, why 3 he --
10 4 MR. JACKSON: We don't know. We don't 5 have a root cause.
6 MR. HEHL: Why he took a shortcut, but 7 the question is -- and it goes with your corrective 8 action -- the question is do you recognize, you 9 know, that there are other issues involved here and 10 have you taken action to fix those other issues?
11 MR. JACKSON: Certainly we're going to 12 be discussing that, but I didn't want you to be f
13 under the impression that ConEdison has come up with 14 a reason why this occurred on this date. Certainly 15 ConEdison does not condone such conduct, whether 16 it's at Indian Point or anywhere else in the 17 company, and we take strong action for such kind of 18 behavior.
19 But in this case, we just don't know 20 why it happened. Perhaps in your investigation, you 21 know, you had some additional information from the 22 individual. We just don't know why. But we 23 certainly are moving on the other issue.
1 24 MR. HEHL: Right now I guess the ALL POINTS REPORTING (610) 272-6731
. 46 i 1 question came up earlier that you're going to l
I 2 address that this is still focused on corrective i
3 actions that focused in the performance group. And 4
I guess are you looking more broadly than that from l
5 the standpoint of other types of surveillance 6 activities associated with operator rounds and other 7 things? Is there any insights here that are moving 8 you into looking at some of those other areas?
9 MR. SAGER: We did one audit of the 10 surveillance that were performed by operators, that 11 was done in January and February time frame this 12 year. And from that audit, there was one
,1 13 observation, but there were no findings associated 14' with those.
15 However, I will also say that those 16 were primarily surveillance tests that involved 17 operation of major equipment. And so there's lots 18 of interaction with groups so they're not 19 susceptible to people being --
20 MR. INZIRILLO: Operations has a 21 practice where they routinely review security 22 records to ensure that operators are getting around I-
} 23 the plant. We are adapting the same practice to 24 make sure that the area of test technician work ALL POINTS REPORTING (610) 272-6731
47 i 1 where they're doing things that doesn't involve 2
turning on and off major pieces of equipment that 3
we're also assuring that they're accessing those 4 areas that we would expect them to access for 5
inspection. '
6 MR. HEHL: That's something that was in 7 place and ongoing?
8 MR. INZIRILLO: In the case of 9 operations, yes. What the frequency of that is, I'm 10 not sure, but I know they do it routinely.
11 MR. TEMPS: It's in the OADs.
12 I MR. HEHL: It's probably a reaction to '
(
13 the Salem issues in the early '90s.
14 MR. TEMPS: Exactly.
15 MR. INZIRILLO: In addition, as far as 16 in the area of supervisory oversight, the test 17 supervisor is routinely coached as to his 18 expectations of his performance. He completed just
-19 recently a two-day training course that he was sent i 20 on on error reduction. And this particular training 21 course focused on the importance of field 22 observations in reducing personnel errors.
1 l
23 In addition, he has been provided with
'l 24 clear direction for improvements in the areas I ALL POINTS REPORTING (610) 272-6731
_______________ _ _ _ _a
l 48 i i discussed earlier, pre-job briefings, pre-planning 2 of jobs, control of work, and has also been directed 3 to, as I stated, to review security records on a 4 periodic basis to ensure technicians are where 5 they're supposed to be as expected.
6 The effort has resulted in an increased 7 attention to detail on the part of the test 8 technicians, as has been indicated by the 9 questioning attitude, and has resulted in a number 10 of procedural improvements in that time period.
11 Also, there's been an obvious increase in the number 12 of open item reports written by the test supervisor, t
13 which is indicative of his increased field 14 performance or observations.
15 In summary, following our 16 identification of the events associated with the 17 50.9 violation, we conducted an exhaustive 18 investigation. The instances were isolated to the 19 ones identified and our notification of corrective 20 actions were instituted which involved the 21 disciplining of the individuals involved. And also 22 we reinforced management expectations to the staff 23 as a result of this event.
I 24 As you had requested and as we kind of ALL POINTS REPORTING (610) 272-6731
49 t
] 1 discussed here a little bit already, you asked us to 2 also look at the training issue and the issue of 3 training and qualifications. We did identify as 4 part of our review that the training program for the l
l 5 test technicians was an area where we can make i
6 improvements.
7 The test technicians are generally l 8 recruited from the nuclear plant operator staff.
9- That position has an extensive formal training 10 program which was taken credit for in their 11 training. The program which existed for the test 12 technicians requires improvement, and we are i
13 embarking on improving that.
14 MR. AXELSON: What technicians are you 15 talking about here?
16 MR. INZIRILLO: These are test i i
17 technicians. We have a group outside of operations I
le that performs technical spec surveillance tests. I 19 MR. AXELSON: It would be all INC i 20 technicians?
, 21 MR. INZIRILLO: No, these are not INC, l
l
[ 22 they're a testing group. They typically do 23 mechanical type of surveillance such as valve 4
24 strokes, INST tests, readiness tests, HVAC testing, ALL POINTS REPORTING (610) 272-6731
50 1- 1 that type of thing.
2 MR. AXELSON: The investigation then
'll 3 seems to have narrowly focused, correct me if I'm 4 wrong, it seems that it's this group that needed to 5 be fixed, the investigation has been isolated just 6 to this one group and the corrective action is 7 isolated to that group. Is that kind of what you're 8 saying? I mean why are you -- what makes you think 9 you don't have a problem outside of this group when 10 it comes to procedure adherence and supervisory l 11 oversight, meeting standards and expectations, 12- chemistry technicians, HP technicians, all the other 1.
13 technicians?
14 MR. INZIRILLO: As Harlan had stated l
15 earlier, there were some looks at other departments. '
16 MR. AXELSON: I know he mentioned some 17 of that, but how did you conclude that it seems --
18 you used the word " isolated." I 19 MR. INZIRILLO: The isolated meant that 20 event which appeared to be an intentional failure 21 to perform the procedures on that day as was l 22 directed. So from when I look at it from at least 23 my perspective in looking at the performance of 24 those. test technicians to ensure that they're doing ALL POINTS REPORTING (610) 272-6731
51 I 1 what I'm expecting of them, I see that event with 2 all the data.that I gathered as an isolated event on 3 that particular day. I couldn't even demonstrate 4 that they had performed the same misoperations on 5 other days. So that level where the amount of time 6 and the failure to enter the --
7 MR. SAGER: One of the things which I'm 8 sure you're aware of too is when we go watch 9 somebody do something, you see very close tolerances 10 to adherence, the fact that you're observing it.
11 It's not necessarily being done exactly the same way
'12 it gets done every time. So what we're trying to do i
13 is identify ways in which we can not be there but 14 still provide other evidence of doing that.
15 Similar to what we did with the test 16 technicians, we'll be looking at the other groups in 17 INC that perform some of these tests. And as part 18 of our ongoing efforts in what we're trying to 19 figure out how do we fold that into some of our 20 reviews. But again, it's not real clearcut how you 21 do that at this point other than the kind of things 22 that we've identified now to try to cross reference 23 and validate that people are where they're supposed 24 to be, that they had the kind of equipment they ALL POINTS REPORTING (610) 272-6731 l
52 l
- 1 needed to use, that they wrote the kind of 2
identification problems you would expect them to 3 write when they see that.
4 MR. INZIRILLO: There's -- we 5 obviously, as I'm sure the record shows, have had l
6 other examples of procedural compliance issues at 7
the station which have been dealt with in the 8 various organizations. Operations has instances, 9 INC has had some instances where we're making 10 efforts to improve training, to improve procedures, 11 to improve communication of expectations on all of 12 those areas, i
13 In this particular case I guess, and I 14 don't mean to give the wrong impression here, I l 15 guess I am focusing on that aspect of procedural 1
16 compliance that affected the test organization and 17 how we can feel confident that that was not --
that 18 we've identified adequately those conditions that we 19 need to improve on. My intention is not to suggest i
l 20 that everywhere else doesn't require any looking or 21 is pristine and this is the only area in the entire L
22 plant that we have anything to worry about it.
23 Even in the training area, we took a 24 broad scope look at other positions in the station ALL POINTS REPORTING (610) 272-6731 I
53 0
i 1 that may have need for improvement in their training 2 programs also. We didn't just look at, okay, here 3 we identified the fact that we have a group of 4 technicians whose training program needs 5 enhancement, we asked for a root cause report to 6 take a look at training across the station and for
- 7. any other positions that may need improvements in 8 their training program.
9' MR. HEHL: I don't want to get too far 10 off the track because I think we do have other 11 forums, and we've discussed a lot of these broad 12 issues and we've got meetings scheduled coming up to
(
13 discuss some of these broader human performance 14 . issues and what you plan to do in a broader scope 15 and scale there.
-16 So yeah, I mean I think it's a good 17 point. I'm glad you clarified that although your 18 presentation appears to be focused in this area, you 19 recognize that there are broader issues, but we also 20 I think recognize that.
21 MR. ROGGE: Frank, I've got a question.
l I
22 Do you think the technicians actually did anything 23 or not that day? Other than just filling out the 24 form.
J ALL POINTS REPORTING (610) 272-6731
, 54 1 .
l l1 1 MR. SAGER: For this particular test l
l 2 that we're talking about?
3 MR. ROGGE: Right.
4 MR. SAGER: In looking at how 5 these tests are done, you see a pattern 6 develop.
7 MR. ROGGE: On that day, did they or 8 did not do it?
9 MR. INZIRILLO: Obviously, on the 10 diesel generator test, I know for a fact that 11 nothing was done. That on the emergency light test, 12 based on the discussions I had with Mr. Vincent, one i
13 of the technicians, it appeared to me that they did 14 do a cursory review of the emergency lights on that 15 day, definitely inadequate, definitely well below 16 expectations. But it was not -- and again, this is il2 17 just purely opinion now -- it was not a punch into 18 the building and just fill out the paper and leave, 19 that there was an attempt, and it appeared like it 20 was a somewhat of a rushed attempt that they were 21 going to do the test.
22 MR. ROGGE: The actual physical 23 conditions found with the battery water level, do i
24 you think it was reasonable that they would not have ALL POINTS REPORTING (610) 272-6731
_ _ _ - _ - _ _ - - = _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _
l 55 i 1 found that?
2 MR. INZIRILLO: If they conducted the 3 test in the inadequate way that I believe they did, 4 I can see where you could, if you look at one of 5 those batteries, you really have to look close to 6 see the water level. And if you walk by it too 7 fast, you may not be able to adequately ascertain 8 the water level or cause yourself to believe that it 9 was acceptable. Again, I'm not trying to make 10 excuses for their performance.
11 MR. ROGGE: I want to leave with one 12 more question, making those conditions and going
!L 13 back to the prior test, were you able to conclude 14 that the prior test was done correctly or does the 15 phenomenon you're seeing indicate that that test 16 also wasn't performed correctly? Did you go to that l
17 extent? Did you get engineering involved to see how 18 far back this condition could exist within a 19 reasonable time and not have been detected? How 20 many other opportunities is what I'm getting at.
l 21 MR. SAGER: We looked at that, but I 22 can't answer specifically to what degree we were 23 able to ascertain that the level change, for j i
24 example, could have only existed this long. f t
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56 i 1 MR. KINKEL: It could have occurred l
2 earlier, but we have no way of demonstrating either 3 way. -
4 MR. ROGGE: There's a reasonable 5 calculation back.
6 MR. KINKEL: But we also have batteries 7 that use a lot of water because they're in warmer 8 areas and that's somewhat ambient.
9 MR. SAGER: What we saw when we looked 10 at this is you see a pattern develop because people 11 have to go in and out of the areas, and if you look 12 at each of the tests that we did for Emergency Route
(
13 Two or Appendix R and one for non-Appendix R, you 14 see a time of going into that room and spending time 15 and coming ou*: to the security access. When I 16 looked at that pattern, it looked like the pattern 17 of what Mr. Stipik did on August 8th followed the 18 test for the PTM test, not the Appendix R. I didn't 19 have a chance to talk with him, I don't know what he 20 was doing. But it doesn't appear to be the same 21' pattern for doing the 49 A or B lights in Appendix R 22 on that day at all that you see that the other i
23 technicians or even he did on the previous days.
24 MR. MILLER: I'm not sure I understand ALL POINTS REPORTING (610) 272-6731 L . . -
l 57 1 1 what you're saying, because I think John started off 2 summarizing the OI conclusions, which among other 3 things included the statement that a number of 4 emergency light tests performed over the previous so 5 many years were not conducted according to the 6 procedural requirements. Now did I hear you say 7 that there was circumstantial evidence that confirms 8 that or the opposite, when you say that there wasn't 9 a pattern?
10 MR. SAGER: What I'm saying is on the 11 Pth, the pattern of performing the test that they 12 signed for was not there. What the pattern 13 exhibited is a different test, which is also the 14 emergency light test.
]
15 MR. MILLER: Different than the one i
16 that they're supposed to do?
17 MR. SAGER: Different from the one that 18 they were supposed to do.
19 MR. MILLER: You have a statement that 20 says your investigation did not reveal other 21 instances of apparent violations. So you've got two 22 conclusions that come up, two investigations coming 23 up with what appear to be, at least on the surface, j i
24 with.two different conclusions. And I'm just ALL POINTS REPORTING (610) 272-6731 !
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58 1 1 wondering what your basis was here.
2 MR. SAGER: What I'm saying is if you 3 look at what rooms you have to go to, how long you 4 roughly spend in those rooms as the pattern if you 5 do test A, you see one pattern; when you do" test B, 6 you see a different pattern; when you do test C, you 7 see still a third pattern. And so if you look at 8 among different operators, the duration and the 9 pattern, you see it's fairly consistent for these 10 tests. It's not identical durations because what 11- happens is frequently that he might be in a room 12 doing other things as well, okay. But you do see 1
13 the general pattern develop.
14 The pattern of what buildings and rooms 15 they went into and how they came out did not follow 16 what you would have expected for the PTM 49 test l
17 that they were doing -- the Appendix R on that date, j l
18 it followed a different test which they were not 1
19 doing. I 20 MR. MILLER: How come on previous 21 occasions --
22 MR. SAGER: On previous occasion, every 23 time I looked at it, it followed that pattern. Wnat f'
24 I did see when you have multiple operators, you ALL POINTS REPORTING (610) 272-6731 l
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59
- 1 sometimes found one operator did these rooms and a 2 different operator did the other rooms.
3 MR. INZIRILLO: It's clear that two 4 things definitely were not being done in clearly 5 compliance with the procedural requirement.
- One was 6 the 60 to 90-second holding of the light. That was 7 admitted to, because I guess there was an 8 understanding, as had been explained, that what they 9 were looking for was that lower stable voltage 10 reading.
13 11 Secondly, that there was a failure to 12 conduct the battery terminal inspections at a i
13 minimum as admitted to on the part of Mr. Vincent 14 because he stated that it was his belief that as i
15 long as the battery was functioning, or the light 16 was functioning properly, the terminals were intact 17 and acceptable.
18 Mr. Stipik's interview did not indicate 19 again from his discussions, except obviously the 20 results of the test on that day bear themselves out, 21 that he had conducted the test as written in the 22 procedure. I can only conclude that his performance 23 on the test on previous occasions might have also --
t 24 might have also have been inadequate in the area of L
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1 terminal inspections. I don't have a fact to show 2 me that and in fact, when we go back and we look at 3 other performance of the test, the timing is j 4 adequate based on the three-minute per light 5 rule that would have been able to do all that. So I 6 can -- I can give an opinion, I can't give a fact 7 that would clearly state what would have occurred 8 except for what occurred that day. That I could 9 factually state that it's evident what was not 10 done.
11 And we did go back and look at it for a 12 year's worth of emergency light tests to see if '
I 13 there was any other similar instances, you know, 14 very quick period of time in an area, we looked at 15 all the emergency light tests, and didn't have 16 evidence'of that.
17 MR. ROGGE: What evidence did you have 18 on how widespread using the stick to do the test 19 was? Did everybody do that, did nobody do that?
20 MR. INZIRILLO: Two technicians said 1
21 that they did not use the stick except in the 22 instance of what I suggested where they were going 23 around and then waiting for the maintenance to bring 24 the up-up so they can go up and do the inspections ALL POINTS REPORTING (610) 272-6731
61
- i. 1 that they would use it for that benefit. And the 2 other-two technicians, Mr. Vincent admitted to the 3 use of it, and as I recall from the statements from 4 Mr. Stipik, he never denied using it. It was --
his 5 statement was somewhat confusing on whether he did 6 or did not use it, but he never denied $t. Unless 7 you interviewed him, I guess I can't give you a 8 clear appreciation for trying to understand the 9 answers to the questions, but he was difficult to 10 understand.
11 As I had mentioned earlier, as we 12 looked at the adequacy of the training and the fact i
13 that we wanted to make some improvements, we did 14 temporarily relieve the technicians from the 15 performance of their surveillance duties so that we 16 could conduct a focused training program which 17 provided them with continuing training in the areas 18 of pump and valve theory, the fire protection 19 program requirements, the in-service testing program 20 requirements, technical specifications, design, and 21 licensing basis procedural adherence. They received 22 a one-day training program in error reduction 23 training, and that's just to mention a few of the 1
24 areas where we provided them with focused training.
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62 1 1 In addition, they were to complete 2 certain required reading for station procedures that .
i 3 identified the requirements for such things as f!
4 procedural adherence. Each went through a personal 5 interview with myself where we discussed standards 6 and expectations and their accountability in meeting 7 those expectations. And subsequent to that, they 8 were put back on for performance of surveillance 9 tests.
10 The test technicians are currently 11 enrolled now in the nuclear plant operator training 12 program. Although the NPO training program is and i
13 will continue to be a key prerequisite for_ entry 14 level test technicians, we are under the development 15 of a new test program which will provide both 16 initial and continuing training that will be more 17 locused on what we feel are requirements for tests.
18 MR. HEHL: When is that going to be in 19 place?
20 MR. INZIRILLO: By the end of tnis 21 month.
I l 22 MS. WALKER: You said that the 23 technicians are generally recruited from the NPO t
24 ranks. Was that the case for Stipik and Vincent?
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. 63 1
1 MR. INZIRILLO: Stipik was, Mr. Vincent 2 was not. He came over from the performance group 3
and currently, as a result of looking at our 4
training program, and we have suspended him for 5
performing any further surveillance tests, he is 5 strictly now associated with performance of 7 thermography, for example, he has been trained 8
specifically for the area of thermography, and we 9 use him for that area.
10 MR. ROGGE: The INPO runs a training 11 program, which you have one, it seems that this 12 group did not fall into that training program. Now, t
13 you're implementing training, is that going to be an 14 INFO training program?
15 MR. INZIRILLO: Yes, sir. As I 16 mentioned earlier, we did take a broad look to make 17 sure thet this type of situation didn't exist ,
18 elsewhere_, and there were no other examples 19 identified.
20 MR. AXELSON: You mentioned quickly the 21 60 to 9 0 - secor.d test , and I think you mentioned that 22 you're not even sure that that was a necessary test.
23 Was it necessary to do the 60 to 90 or was it not?
- t 24 MR. INZIRILLO: In discussion with the i ALL POINTS REPORTING (610) 272-6731 l
64 i i system engineer, the performance of the battery 2 would be such that once you push the button in, 3 voltage would drop off to some new level. And 4 before it would decay off from that point, it would 5 stay at that level more a period of time longer than 6 90 seconds.
7 But my purpose for bringing that up is 8 that our expectation is not that the technician make 9 an assessment as to whether or not that 60 to 90 10 seconds is what should be there or not. That's what 11 the procedure says, and that's what's requ red.
12 MR. AXELSON: And I understand that, i
13 but what did your investigation -- is it 14- necessary -- was it a necessary test for 60 to 90 15 seconds to pass the surveillance?
16 MR. INZIRILLO: Currently, we've left 17 it that way. I want to get something from the 18 manufacturer, but we have not changed that. So as 19 far as I'm concerned, it's necessary.
20 MR. MILLER: Okay, let's go on.
21 MR. INZIRILLO: Unless there are any i 22 other questions.
l 23 MR. JACKSON: That concludes the 24 licensing summary.
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i 1 on the two issues that were raised, 2 John, on the' violations, basically one was 50.9, we 3 provided you notification in accordance with 50.9 on 4 October 8th, the day after we concluded our 5 investigation, and then we promptly notified Agency 6 representatives when we found the second event. But 7 we had investigated and we had -- the investigator I 8 believe was onsite or we phoned him, and I think 9 Rob, you were notified also of the second event that 10 we found on that date.
11 We do not -- we recognize on the 12 broader issues that there are performance problems.
I 13 We do not believe, however, that those were specific 14 root causes for the actual violation. We do not 15 know, as I said before, motivation or specific 16 reason why an individual falsified a record, 17 particularly the second event, we just don't know.
18 But it occurred, and our investigation we believe 19 concluded that it did indeed occur.
20 Regarding prior compliance with the 21 licensed condition on Appendix R, although there
, 22 were performance problems in performing the testing l
23 fully in accordance with the procedure that we had i
24 issued, there was a considerable history of ALL POINTS REPORTING (610) 272-6731
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- 1 maintenance activity on the lights. We went back, I 2 believe we said 1988, and looked. We had them i
I 3 average approximately 30 work orders.
4 MR. SAGER: 39 work orders per year.
5 MR. JACKSON: So that there was 6
maintenance activity taking place, there was testing 7 activity. There was the potential for that testing 8 activity to be fully in accordance with our 9 expectations. And although we don't have specific
- 10. instances of that, we do have records from our 11 investigation that testing and maintenance was 12 occurring for the emergency lights for the Appendix
(
13 R. Those are the two issues.
14 We have discussed the broader issues of 15 the areas for improvement that have come out of 16 various investigations, and we have taken or are in 17 the process of taking the corrective actions in 18 those areas.
19 MR. MILLER: I'd like to make some 20 comments here. And first of all, I mean it's good ;
21 that you had enough of a review here that you were 22 able to find this other instance, you know, of the 23 diesel generator. But just looking at what you j i
24 prepared here to present, I'm disappointed, because ALL POINTS REPORTING (610) 272-6731 m
67 1 it appears to me like you are focused too much here 2 on the isolated, too much on you told everybody 3 what's expected.
4 I guess I would disagree with what's i
5 written here on your conclusion page. I would 6 question, just by looking not just at this event but j 7 the other instances, that we too often have found, 8 not you, where people are not doing the complete 9 job, are not following procedure the way they should 10 be following procedures, the laxness, the 11 informality, the I'm smarter than the procedure, I 12 know better than the procedure, the procedure is 13 wrong, I know it's wrong.
14 There's a pattern that's just too 15 strong to conclude that you've adequately 16 communicated what your standards and expectations 17 are with respect to adherence to procedures and 18 strictly following the program. And I think also 19 that it seemed to be more in the give and take and 20 in the questioning that the other very fundamental 21 thing came out which is, you know, getting the 22 feedback. It's one thing to be communicating the 23 standard, but it's a second thing to go find out if 24 the standard is being heard and understood, which ALL POINTS REPORTING (610) 272-6731
e 68 I7 1 gets you to this question of oversight, which gets 2 you to the question of involvement.
3 You know,.there are very many 4 mechanisms are out there, and most of all line 5 management'being involved in the field, but also QA 6 and the other techniques that you have. But I think 7 that the emphasis on this one day, on one day, he 8 did one thing but we told him, we adequately 9 communicated what our standards are, I think that's 10 not right.
11 You know, I'm just telling you what I 12 feel from not looking just at this, but also the f
13 other things that are out there in the way of a 14 record on performance at Indian Point over the last 15 several years. I think it's important for you to 16 recognize that and to face up to it, because I think 17 if you don't, you're not going to be successful.
15 18 It's an issue of standards, standards 19 and oversight. Real pure and simple. And I don't 20 know that you have adequately communicated them. I 21 don't know. And again, it bothers me a little bit i 22 that it took the give and the take to have you tell 23 us that you recognize that oversight is a piece of 24 it. I'm just giving you my reaction.
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{ 1 MR. JACKSON: Clearly our intent, as 2
you said, was we presented information regarding the 3 specific events and items. It was not our intent to 4
come down and discuss the broader standards and 5 procedural issues which we are addressing at=the 6 station..
7 MR. MILLER: I've held back here a 8 little bit trying to see how it came out. I think 9 that's a mistake. I think you've got to look at 10 this as part of the broader issue at Indian Point.
11 I think if you do continue to piecemeal these 12 things, I think you're going to be missing the boat.
I 13 MR. AXELSON: Do you see this as part 14 of the broader issue?
15 MR. KINKEL: There's no question it's 16 part of the broader issue.
17 MR. MILLER: It's part of the broader 18 problem. I'll tell you, it's a slippery slope to be 19 on, because your folks can most of the time 20 rightfully argue that the procedure was flawed in i 21 some way. Like when we reestablish RHR, I think it 22 was RHR, and you're supposed to set the flow in this 23 range. Well, we know the engineers have said don't I
24 do it in that range because that is the kiss of l I
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70 1 1 death because they'll be right some large number of 2 times, but they'll be wrong some number of times and 3 then you're really in trouble. And it's an 4 insidious thing too, because the number of times 5 that they're right just reinforces this sense of 6 invincibility and this sense that I don't have to I 7 follow the procedures and then these machines are 8 too complicated to run just all from up here.
9 That's why you have procedures.
10 And there's a lot out there that's l
11 counterintuitive. And so this business of following 12 procedures is there because the industry and we've 13 learned the hard way, if you don't do it that way, 14 you're just setting yourself up for a big problem at is some point. So this is the issue at Indian Point.
16 And this is why I guess I'm concerned to hear this, 17 I think it is vital that you see it as part of the 18 bigger problem. Otherwise you're going to continue 19 to undershoot on the fix. I'm just giving you a 20 general reaction to this thing.
21 MR. HEHL: Just, you know, and going 22 along with this, I mean a lot of the -- you know, l
23 speaking in'a broader sense, a lot of the things i
24 that we've got to work through as far as a licensing l ALL POINTS REPORTING (610) 272-6731 e - - - - - - - - . - - - - - . - - - - - - _ - - - - - - - - - - - - - . - - - - - - - - - - - - - - - - - - - _ - - - - - - - -
e 71 1 1 regulator is essentially reestablishing the 2 confidence that you're pursuing these broader 3 issues. And I'll tell you every interaction we have 4
is an opportunity to either reinforce that you've 5 got the message that you're moving in the right 6 direction or it's an opportunity to raise questions 7 again on whether or not you've focused in a very 8 small isolated place.
9 And so, you know, I would just 10 certainly suggest that you take that consideration 11 in all future interactions with us as, yes, you've 12 got to answer the specific questions, but please 13 take the opportunity to go further than that and 14 communicate to us your sense of where this fits with 15 regard to the broader issues involved.
16 MR. MILLER: This conference is in some 17 respects more important than the one this morning.
18 The one this morning we've already been down that 19 path 10 times before so we're settling up kind of an 20 enforcement space at the beginning of that meeting.
21 But this meeting has to do with what I think is the 22 more important issue of Indian Point 2, and that has 23 to do with standards with respect to human
(
24 performance, I mean the more tractable thing.
l l
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72 3 1 Equipment problems are harder to spot but easier to 1 2 fix.
3 These are things that if you can never, 4 ever feel, especially when you've had lax standards 5 for a long time, that you can tell somebody one time 6 and you solve your problems. This is the one that's 7 going to take you a much longer time to fix. You've 8 got to be looking at this broader issue. Use it as 9 an opportunity to recalibrates the whole station and 10 err on the side of over rather than underplaying the 11 issue when it comes to this whole business of human 12 performance standards. Because there are still 1
13 people at the station who believe that the issues 14 really are some problem management has, some problem 15 that the maintenance people have, some problem that 16 the engineers have, where it's really it's an issue 17 of standards.
18 And human performance is the issue in 19 this one and too many of the other instances over
- 20. the past year. So it's important we communicate.
21 And I'm communicating, I'm telling you what our 22 reaction is to this. Do you agree, Paul?
l
( 23 MR. KINKEL: We heard you. We agree.
I
-24 MR. JACKSON: We were here about a l
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I . .
73 '
] 1 month or two ago and we were talking about the l j l
2 general overall performance issues. And I think the l )
3 standards, communicating the standards reinforcing I
4 was the theme that at least we saw in each of the I 16 5 areas that we're working on.
)
j It wasn't limited to 6 just one group or one part of the operation, but it 7 was across the board.
l 8 MR. MILLER: But you see why I'm 9 reacting to this?
10 MR. JACKSON: I see exactly. We put 11 this together to answer the mail specifically on the 12 one issue and --
I I 13 MR. MILLER: I think you've got a 14 credibility problem essentially, but I'm more 15 worried about your getting the station on the right !
16 course. That's the most important thing. I'm l l l 17 worried about what you're doing with your employees, i 18 that's what I'm worried about. I'm worried about I 19 what you're doing to establish the right standard 20 there. The ISA said it's a leadership issue, that's 21 what this really is.
l 22 Do we have anymore from our side? I 23 think we have what we need. Appreciate it. We'll I
24 be back in touch. We'll see you on site in a week l
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74 6
7 1 and a half, on the 18th. Thank you for coming down.
2 (Proceedings closed.)
3 ...
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l CERTIFICATION I, Loretta B. Devery, do hereby certify that the testimony and proceedings in the foregoing matter, taken on May 6, 1998, are contained fully and accurately in the stenographic notes taken by me and that it is a true and correct transcript of the same.
V$L
'LORETTA B.
- ff Mur DEVERY, R[
g NOTARIAL SE'A!.
ICAETTA B DE /ER$ uan Puche Lower Soutnampton No L.ks county Vy Comm syqn Ero7s Aunust 13 /M1 The foregoing certification of this transcript does not apply to any reproduction of the' same by any means unless under the direct control and/or supervision of the certifying reporter. j l
1 l
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