ML20155J591

Submits Memo Entitled, Results of NRR Investigation & Evaluation of 10 Licensed Operators Involved in TMI-2 Preaccident Leak Rate Testing Irregularities. Tests Conducted in Frivolous Manner & Results Sometimes Falsified

ML20155J591
Person / Time
Site:	Three Mile Island
Issue date:	04/01/1986
From:	Stello V NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO)
To:	Asselstine, Palladino, Roberts NRC COMMISSION (OCM)
Shared Package
ML20151L202	List: ML20151L198 ML20155J582 ML20155J591 ML20155J599 ML20155J625 ML20155J636 ML20155J641 ML20155J649 ML20155J653 ML20155J677 ML20155J684 ML20155J692 ML20155J704 ML20155J710 ML20155J713 ML20155J726 ML20155J745 ML20155J753 ML20155J770 ML20155J778 ML20155J792 ML20155J808 ML20155J825 ML20155J835
References
860401, CLI-85-02, CLI-85-18, CLI-85-2, NUDOCS 8605270108
Download: ML20155J591 (39)

Text

>

1

)

UNITED STATES

.3UCLEAR REGULATORY COMMISSION WASHINGTON, D. C. 20555 LIMITED DISTRIBUTION APR 01 IBBS irman Palladino issioner Roberts

. issioner Asselstine issioner Bernthal issioner Zech ctor Stello, Jr.

ting Executive Director for Operations SULTS OF NRR'S INVESTIGATION AND EVALUATION OF TEN CENSED OPERATORS INVOLVED IN TMI-2 PREACCIDENT LEAK TE TESTING IRREGULARITIES l

orandum is to inform the Commission of: (1) the Office ulation's (NRR's) general findings and conclusions reactor coolant system leak rate surveillance testing e Island, Unit 2 (TMI-2); and (2) NRR's conclusions and ing ten licensed operators involved in preaccident leak ities. With respect to the ten operators, NRR's report t wrongdoing and the current performance of the ce of Investigations (OI) Report (1-84-022), which ing only, is being forwarded to the Commission by OI ssion meetings on March 23, 1984 and May 23, 1984, 01 to jointly investigate what role, if any, ten licensed roper activities associated with reactor cociant system ~

testing at THI-2 before the accident. Based upon the I/NRR investigation into past wrongdoing and NRR's viduals' current performance, NRR was to recommend to ion covered in this memorandum and enclosures is the n ongoing OI investigation and information that is n the NRC's Privacy Act System of Records (NRC-16).

um and enclosures may not be disseminated outside the coordination with NRR and the permission of the ED0 or

, 01.

Internal access and distribution should be on a w" basis.

ussell, NRR 20 R

b ;[  %,

a UNITED STATES NUCLEAR REGULATORY COMMISSION

$ I wAsMINGTON, D. C. 20558

...../ LIMITED DISTRIBUTION APR 01 5 MEMORANDUM FOR: Chairman Palladino Comissioner Roberts

' Commissioner Asselstine

'Comissioner Bernthal

. Comissioner Zech FROM: Victor Stello, Jr.

Acting Executive Director for Operations

SUBJECT:

RESULTS OF NRR'S INVESTIGATION AND EVALUATION OF TEN 3 LICENSED OPERATORS INVOLVED IN THI-2 PREACCIDENT LEAK RATE TESTING IRREGULARITIES i

Purpose The purpose of this memorandum is to inform the Comission of: (1) the Office O .

of Nuclear Reactor Regulation's (NRR's) general findings and conclusions regarding preaccident reactor coolant system leak rate surveillance testing practices at Three Mile Island, Unit 2 (TMI-2); and (2) NRR's conclusions and l

recomendations regarding ten licensed operators involved in preaccident leak rate testing irregularities. With respect to the ten operators, NRR's report addresses both the past wrongdoing and the cur,ent performance of the individuals. The Office of Investigations (01) Report (1-84-022), which addresses past wrongdoing only, is being fontarded to the Comission by OI

. under separate cover.

Background As the result of Comission meetings on March 23, 1984 and May 23, 198A, 0! l and NRR were directed to jointly investigate what role, if any, ten licensed individuals had in improper activities associated with reactor coolant system

' leak rate surveillance testing at TMI-2 before the accident. Based upon the results of the joint OI/NRR investigation into past wrongdoing and NRR's evaluation of the individuals' current performance, NRR was to recomend to 4

NOTE: The information covered in this memorandum and enclosures is the .

subject of an ongoing OI investigation and information that is maintained in the NRC's Privacy Act System of Records (NRC-16).

, The memorandum and enclosures may not be disseminated outside the -

NRC without coordination with NRR and the permission of the EDO or O the Director. 01. Internal access and distribution should be on a "need-to-know" basis.

Contact:

William T. Russell, NRR 492-4803 8605270108 860516 PDR ADOCK 05000320 P PDR ,

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

During the course of the joint investigation, some individuals may have made false statements regarding thcir past involvement in leak rate testing irregu-larities. Since these individuals were licensed senior operators, it was necessary for NRR to detemine whether or not the individuals should be allowed to continue to perfom activities related to public health and safety. NRR evaluated each individual's past improper conduct, the completeness and accuracy of his testimony, his knowledge of licensed duties and responsibilities and his current perfomance. NRR's report balancing these factors was prepared for each individual shortly after their interviews. Copies of these reports are included,as enclosures 3 through,12.

By memorandum from the Executive Director for Operations (EDO) dated December 18, 1984, copies of the NRR reports for the San Onofre 2/3 operator and both s

Waterford 3 operators were provided to the Commission. 01 and NRR briefed the

) Commission on the investigation results and NRR's recommended actions. The m,/ Commission subsequently decided to defer a decision on actions against these individuals until the entire investigation was completed.

In its February 25, 1985 decision (CLI-85-2), the Comission decided it would institute a hearing on the TMI-2 leak rate falsification issue. This hearing was to develop the facts surrounding leak rate falsification at TMI-2 in sufficient detail to detemine the involvement of individuals. As a result of this Commission decision, NRR has not implemented its recommended actions.

Discussion As part. of the investigation, NRR perfomed a technical evaluation of leak rate tests performed during the last 6 months of operation at TMI-2 and 01/NRR inter-viewed the ten individuals under investigation. In order to gain additional background information, 01/NRR conducted interviews with five former THI-2 control room operators (CR0s) who stood watch with the individuals under investigation. Based upon operator interviews and the technical evaluation of leak rate tests, NRR developed general findings and conclusions regarding leak rate surveillance testing practices at TMI-2 during the period October 1978 through March 1979. These general findings and conclusions are provided as Enclosure 1.

On September 9, 1985, GPU Nuclear Corporation (GPUN) forwarded its investigation report, entitled "TMI-2 Reactor Coolant Inventory Balance Testing," prepared by Mr. Edwin H. Stier (Stier Report). This report addresses leak rate surveillance

\*j testing practices at THI-2 for a 1-year period before the accident. The Stier Report findings regarding leak rate testing practices and test manipulation are generally consistent with NRR's conclusions.

1

. Enclosure 2 contains a sumary of NRR's findin 1 tions (extracted from Enclosures 3 through 12)gs, for the conclusions ten individuals and recomenda-under investigation and where applicable, includes a synopsis of the Stier Report conclusions regarding these individuals. Transcripts of the OI/NRR interviews and NRR's technical evaluation of leak rate tests have not been included in enclosures 3 through 12 since copies of these documents are exhibits in the 01 j Report (1-84-022). Enclosures 13 through 17 are NRR's background interview l sumaries of five other operators. l Conclusion ,

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

. on February 29, 1984. NRR's technical evaluation and operator testimony during the joint OI/NRR investigation confirm that many of the practices associated with the performance of leak rate surveillarce tests at THI-2 violated the technical specifications and approved plant ' procedures. It is also apparent that licensee's standards for procedural compliance in this area were lax and pennissive. This attitude towa- rocedural compliance was created by super- i visory and management personnel.

The leak rate surveillance test was the only method operators had to quantify O unidentified leakage in order to demonstrate compliance with the THI-2 Technical Specifications. Because of the variability of the test results, most operators did not consider the test to be a true measure of actual plant leakage. Based on postaccident evaluation of the leak rate test procedure, the

operators were correct. NRR believes that many instances occurred where leak rate test results were in excess of the technical specification limit; yet, the actual unidentified leakage did not exceed 1 gpm.

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

specification limits, a conscious decision was made by Shift Supervisors, and

possibly managtment personnel, to disregard the requirements of the technical specifications. While direct leak rate manipulation did occur on some shifts, j it is apparent that all shifts perfonned the test with little regaWTor its 1 i

validity. If test results exceeded the technical specification limit, the l results were discarded and another test conducted. If test results were below-  !

the technical specification limit, they were retained to satisfy the '

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

i

! Based on the Commission decisions discussed earlier, NRR has not implemented its

! recomended actions for these currently licensed operators. , , _

i l

l

. . /

, s 1

Recomendation As a result of the Comission's Order dated December 18,1985(CLI85-18) instituting a hearing on this matter, no Comission action is recommended at this time. Pursuant to CLI-85-18, the staff will make reconsnandations to the Comission subsequent to the Presiding Board's issuance of its findings of i fact. This' report is being provided to complete the action required by the

!. Commission's staff requirements memorandum (SRM) dated April 2,1984. .

i An unexpurgated version of this report is being provided to the Commission; however, the staff has identified certain portions of this report which should be protected from public disclosure pursuant to the Privacy Act,10 CFR Part 9-and 10 CFR 92.790(a) of the Comission's Rules and Regulations. The staff is currently reviewing this memorandum and its enclosures and is making the required deletions. When tne OI Report is available for public release, copies of the 01 Report and the expurgated version of this report will be provided to

< O Document Room, and the Local Public Document Room.the Presiding Board, Original signet tr Yictor Stello I

Victor Stello, .Jr.

Acting Executive Director for Operations

Enclosures:

As stated cc: B. Hayes cc w/ enclosures 1 & 2 only:

SECY OGC i

OPE i-

__,--_m_ _ - _ . _ - , _-__._,.,-.,_.__.,,,_%,. ., __ ,m.yy ,_,,_-,,,%.-my recy-- w.

- - , . - - - . - - , _ _ _ _ , , , ,_-_m-, n r .,

i ENCLOSURE 1 FINDINGS AND CONCLUSIONS REGARDING TMI-2 LEAK  :

RATE TESTING i

l 1 INTRODUCTION  ;: i i NRR has worked with 01 on investigations of 10 currently licensed operators in order to determine' their involvement, if any, in improper activities ,

j associated with reactor coolant system (RCS) leak rate surveillance testing j

at TMI-2 before the accident.

/

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

- - investigation, identifying the individual's role in leak rate testing On the a

irregularities and evaluating the individual's current performance.

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

' Therefore, the purpose of this enclosure is to provide a consolidated summary

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

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

i . 2 TMI-2 REQUIREMENTS '

TMI-2 Technical Specification 3/4.4.6.2, " Reactor Coolant System Operational Leakage," provided the limiting conditions for operation (LCO) associated

" -. with RCS leakage, the surveillance requirements to be performed to demon-strate conformance with the LCO, and the required action statements if the.

LCO vere exceeded.

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

To demonstrate conformance with the LCO Surveillance Requirement 4.4.6.2.d i

required the performance of a reactor coolant system water inventory balance i

' (leak rate test) at least once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady-state operation,

-- I while in Modes 1 through 4 _

NOTE: This enclosure discusses information which is the subject of an ongoing 01 investigation. This enclosure may not be disseminated

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

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

~

Surveillance Procedure (SP) 2301-3D1, "RC System Inventory " was'the approved I procedure governing the conduct of leak rate tests. Section l 2 of the

! procedure stated that if unidentified leakage exceeded 1 gym, the operator was to proceed with Technical Specification Action Statement ,3 4.6.2.b.

In addition, Section 6.4 of the procedure required the operator to conduct the following four steps:

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

(2) Whether unaccounted for operator action had occurred that would change  !

the RCS inventory was to be determined. If such an action occurred, it

i. invalidated the measurement. The action invalidating the measurement l was to be recorded in the remarks section of the data sheet.

i.

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

! (4) If the source of leakage was found, the source of the leakage and ~

! . the leak rate were to be documented and entered on the appropriate

- data sheet. The shift supervisor was then required to make the- 4 initial determination of the safety implications of the leak.

1 According to SP 2301-3D1, the preferred method of performing leak rate tests

O was with the plant computer. To initiate the test, the operator would enter the proper codes into the computer, including the duration of the test. In all cases that were evaluated, a test period of 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> was selected. The j computer would automatically collect the necessary plant data at the "

i beginning and end of the test period. At the end of the 1-hour test period, i the operator was required to enter known leakage and any operator-caused changes in inventory from the reactor coolant drain tank (RCDT) or the RCS.

• j The computer would then print the initial and final values of key plant ,

i parameters and the calculated values for gross leak rate, total identified

! leak rate, and net unidentified leak rate. l The computer-generated leak rate surveillance test sheet would normally be ,

signed ator (SRO by)the

. CR0 performing the test and approved by a senior reactor oper-In j TMI-2 Technical Specification 6.10.1, " Record Retention," required that

! records of surveillance activities required by the Technical Specifications be retained for at least 5 years. i i  !

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

Required entries included the title and number of the test performed and the j start and completion times, or time of suspension, of the test _. i

, Section 6.5 of TMI Administrative Procedure 1010. " Technical Specification l SurveillanceProgram,"requiredoperatorstorecordanygroblemsthatwere i encountered while performing surveillance testing on an Exception and i

! Deficiency List." This list was to be attached to the completed Surveillance '

Test Data Sheet. All exceptions and deficiencies were to be immediately l

i l

i

i i

j evaluated and initialed (to show review) by the shift supervisor.to' determine

! if they constituted a reportable occurrence. The procedure further defined a a " deficiency" as a problem relating to the test results not metting the i acceptance criteria of the test.

..r ~

i 3 TECHNICAL EVALUATION During the period under investigation, September 30, 1978 to March 28, 1979,

plant records show that 161 leak rate surveillance tests were retained by the l

licensee. Documentation for each test was evaluated by NRR to determine i whether the test met the acceptance criteria and whether operator actions or j plant conditions may have occurred during the test that violated the limits i and precautions of SP 2301-301, thus rendering the test invalid. All of the i 161 tests were classified as valid or invalid. The invalid tests were further subdivided into at least one of eight categories as shown by the table below: ,

j Sumary of Leak Rate Tests by Evaluation Category

'-. - Evaluation Category Number /5 Total Tests on F11e........................................... 161 Valid Tests................................................... 50 31 1

t

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

• Unstable or inaccurate data provided to the plant computer.. 42 26 l

~

• Water additions not included in the calculation............. 22 14 .

{

!.

• Water additions partially included in the calculation....... 17 11 I '

~

• Feed and bleed operations not included in the calculation... 15 9 1

• jiydrogen additions to the make-up tank (MUT).. . . .. . . . ..... .. 12 7~

• Unstable plant condi tions during test. . . . . . . . . . . . . . . . . . . . . . . 10 6 l

• WaterorhydrogenadditiontoMUT(unabletodifferentiate). 7 4

• Unidentified leakage greater than the TS limit...'........... 6 4 l

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

j 1

I .

I

. v - .

, 4-i As can be seen by this table, only 50 of the.161 leak rate tests were evalu-1 ated as being performed in accordance with approved plant procedures and yielded results that wf.re less than the technical specification-limit. A brief discussion of each of the test categories is provided balew.

3.1 No Apparent Problem -2 I This category was used for tests that appeared to have been conducted in i accordance with the requirements of SP 2301-3D1. The surveillance test sheet CRO's and Shift Foreman's Logs, and makeup tank (MUT) strip chart had no unusual characteristics or features that called into question the validity 4

of the test. In addition, the actual change in MUT level during the test was consistent with the expected change caused by differences in pressurizer level (Lp) and average RCS temperature (Tave) during the test.

1 During September 30 through December 31, 1978. 30 normal tests were performed l outof82(37%). These tests were fairly well distributed between the fivg j

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

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

- of the pressurizer through either the pilot-operated relief valve (PORV) and/or code safety valves, this was a period where satisfactory leak rate l .." tests became harder to obtain. Duringthisperiod,only20outof74(275) tests were considered normal. The majority of these tests were performed by shifts A and F.

3.2 Unstable Plant Conditions

{ SP 2301-3D1 directed that the test be performed at least once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />

! during steady-state operation when in Modes 1 through 4. The procedure ~

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

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

i valve lineups, coolers in service, pumps in service, etc. Power level

! changes should be minimized, and the operator should avoid additions or i". removal of water from the RCS and makeup system during the test. For the i - most accurate determination of RCS leak rate, the initial and final

! conditions of reactor power. RCS temperature, pressure and pressurizer level j should be identical. Tests in this category had obvious problems with large '

fluctuations in key plant parameters and were not conducted during stable j plant or steady-state conditions.

1 i

During the 6-month period 10 tests were conducted during unstable plant I i conditions. All six shifts were involved in conducting one or more of these j 1 tests.

3.3 Instrumentation Problems ,

Makeup tank level is one of the key plant parameters used in.the leak rate calculation. At TMI-2. there are two level transmitters (LT-L and LT-2) that provide MUT level indication. The output of one of the level transmitters 0

4 t

3

- - - - - - - - . ,-,.,,-r,e,--r--,-~,---,, .- .~m. - . _ ,,- - - .w -w- . . - - ,

l i

j drives the MUT level strip chart in the control room while the other level

! transmitter provides MUT level indication to the plant computer. When the -

selector switch was positioned to LT-1, the strip chart recorder-would be j

driven by the output of LT-1 and LT-2 would provide automatic input to the plant computer. When the selector switch was changed to LT-2rthe opposite would occur. ,

j Between October 30 and November 6,1978, operators experienced ' problems with 2 both level transmitters. At various times during this period, the level l

transmitters were reading radically different levels in the MUT, and both 3 were taken out of service for maintenance work and recalibration. During ,

i this period, eight leak rate tests were conducted. Only two of the tests appear normal. During four of the tests, the difference between LT-1 and LT-2 ranged from 13 in. to 15 in., and during two of the tests, the LT l

feeding the computer was reading off-scale high at 99 in. Only the shift A j operators were not involved in any of the six invalid tests.

.Beginning in early December 1978 and continuing through January 11, 1979, the i output of LT-1 became very erratic and unreliable. Because of the erratic i nature of the output of LT-1 during this period, any leak rate tests l '_, perfomed with the use of LT-1 providing input to the computer must be 1 . considered questionable or invalid. Of the 50 tests conducted by all shifts during this period, only 16 (32%) were perfonned with the stable level transmitter (LT-2) providing input to the computer during the test. During this period, all shifts switched back and forth between the two level transmitters and ran tests using both LT-1 and LT-2. These actions suggest

that operators were aware of instrumentation problems at the time.

]

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

~

positive suction head for the RC makeup pumps, a hydrogen overpressure was.

maintained in the MUT. When hydrogen pressure decreased near the low end of

! the operating band, the CR0 would add hydrogen to the tank.

) c i

~

Theoretically, the addition of hydrogen should not have affected MUT level; i however, because of the design of the MUT level detection instrumentation; i system.at TMI-2, water could collect in the low-pressure (dry) reference leg of the level transmitters. Under this condition, the resultant water slug or

! " loop seal" could cause a temporary increase in MUT indicated level without

! actually adding water to the tank. Thus, the addition of hydrogen at the l appropriate time (after the computer collected its initial data and before the final data were taken) could affect the leak rate results in a i nonconservativemanner(i.e.,thecalculatedleakratewouldbelessthanthe j actual leak rate). According to former CR0 Harold Hartman (Shift E), this "cause and effect" relationship was comon knowledge among operators.

j l

Hartman and four other CR0s on shifts C, D, and E have admitted adding

, hydrggen to the MUT during leak rate tests to influence the otttcome of the tests. Out of the 12 hydrogen additions identified in the technical I -

t

i .

l .

~

< evaluation, the majority were performed by operators on shifts B and C.

Shift A is the only shift where no hydrogen additions were identified during

- leak rate tests. However, this method of test manipulation may have been used more times than are reflected in the technical evaluatiofr for three ,

reasons. First, hydrogen would have an effect on.MUT level oilly if

sufficient water were present to form a loop seal. Second, water might collect in the reference leg of one LT and not in the other. Thus, causing  ;

one LT to react to the addition and not the other. Third, hydrogen additions  ;

! were not always logged, or if logged, were not always logged at the time the addition was made. Thus, identifying the addition of hydrogen on the MUT strip chart is difficult. j j

! 3.5 Water Additions not Included in the Calculation  !

l SP 2301-301 instructed the operator to avoid the addition and removal of water from the RCS and makeup system during the test; however, if the in-

.ventory must be changed, it must be accounted for by including the amount of water added in the test calculation. Norssily, water was added to the MUT in i a manner that is easily detectable on the MUT strip chart (batch addition).

If, however, water was added i,n small quantities over a period of time l'. .. (jogged addition), the water addition may be masked by normal oscillations on the MUT strip chart. According to Hartman, jogged additions were made to the j RCS during the performance of leak rate tests by his shift and the amount of l

water added was not included in the test calculation in order to manipulate i the outcome of the test. The technical evaluation identifies tests where

batch additions and possible jogged water additions were made to the MUT

during the test and not included in the leak rate calculation.

~

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

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

i followed by shift B with six tests and shifts C and D with five tests. Shift

. A and F operators were involved in only two and three of these tests, 2 ,f respectively.

i 3.6' Water Additions Partially Included in the Calculation .

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

^

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

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

The first factor was an error in the test procedure itself. SP 2301-3D1 did

not convert the amount of water added to the same temperature as the RCS. As

! a result, the water added to the MUT was " undervalued" and tended to reduce l' the total and unidentified leak rate as calculated in the test. (Note: This '

! error was only one of several that contributed to inaccurate results.)

~

!O i I 4

,-.--,---,------,,-,-n,-,,--.,,-n.,- n,,_.,n- ,ee. ,,nn--.-n,-n n ,--e,,-,,,.---,,n,,,_,,-_,-,-emv.,,,----n-,-mmmmm,,--t,.,--,-n-

1 l

The second factor involved MUT level instrument errors. Because adding water  !

to the MUT compressed the hydrogen gas in the top of the MUT, water additions to the tank shortly before the computer obtained its final data. set could have the same result as a hydrogen addition. If an operator were aware of

this cause-and-effect relationship, he could take advantage 6f this phenome-non to manipulate test results by following the procedure exact.ly as written.

For example, the addition of 150 gal of water to the MUT duririg' the last 10 minutes of a leak rate test should cause the MUT level to increase approxi-mately 5 in. (30 gal / inch); however, if sufficient water had collected in the loop seal, the indicated level on the MUT strip chart might actually increase l

6 in. (180 gal). Once the final data were read by the computer, including the 6-in. rise in MUT level, the operator would enter the 150-gal water addition (as read off the totalizer on the batch controller) into the computer as an operator-cause change. Thus, when the computer calculated the I

total and unidentified leak rate, the results would be 0.5 gpm less than the actual leak rate (180 gal-150 gal /60 min). Note: While operators used 30 gal / inch as a rule of thumb, the actual value was approximately 30.8 gal / inch _

- at normal MUT conditions. - .

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

'-' - Coleman (Shift D), who was aware of the MUT level instrument inaccuracy and i

used this mechanism to influence leak rate tests, other operators al'so may

' have been aware of the phenomenon and used it to their advantage.

) The technical evaluation identifies 23 tests where water was added to the MUT t and the water addition was included in the test calculation. For six of -

these tests, the amount of water included in the calculation closely matches the amount indicated on the MUT strip chart. Four of these tests were per-l formed by shift A with the other two tests were performed by shifts D and F.

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

{ .

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

Shift D operators were involved in 12 of these tests, shift F in 3 tests, and l , , shift A and B operators each performed 1 test.

i"-

l 3.7. Feed and Bleed Operations l

The technical evaluation identifies 15 tests during which feed and bleed' '

operations may have occurred. Feed and bleed operations were used routinely

to increase or decrease the boron concentration in the RCS. Based on the i limits and precautions of SP 2301-3D1, feed and bleed operations should not have been conducted during leak rate tests.

! Feed and bleed operations, like many others in the plant, do not always have a distinctive trace on the MUT strip chart. At times, water was added (feed) and then removed (bleed) from the RCS, in that order. At other times, the

,' reverse order was used. Because water also could be added and removed from '

( 4

4 i

}

. ~8-i the system at the same time, these operations might be undetectable on the

strip chart if the rate of addition and removal was equal and the operation was not logged in the Control Room Log. While feed and blee % rations could be used to manipulate test results, none of the operator _s. interviewed

~

by OI/NRR have admitted using this method. 7

! Shift C operators were involved in 7 of the 15 tests where possible feed and l bleed operations occurred during the test. The remaining eight tests were j split fairly evenly between shifts B D, E, and F. Only shift A operators j were not involved in any of the 15 tests.

) 3.8 Water or Hydrogen Additions i

i The technical evaluation identifies seven tests where it appears the test j results may have been influenced by either a hydrogen addition or a jogged i

water addition. On the basis of the similarity in MUT level traces that -

could be produced by either a small water or hydrogen addition, it was not-

!. possible to differentiate between these two types of additions for these j - seven tests.

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

3.9 Unidentified Leakage Greater Than I com I

The six tests in this category all occurred between October 16 and 18, 1978.

Each of these tests showed results greater than the technical specificatien

! limit for unidentified leakage. Four tests were not signed by the CR0 I performing the test, and five were not approved by the shift foreman. The sixth test was not signed by a CRO, instead the shift foreman signed as the. ,

operator performing the test and the shift supervisor approved the test. All six tests were associated with an incident that occurred on October 18, 1978, i . resulting in the submission of LER 78-62/1T by Met-Ed on November 1,1978.

{ 3.10 Technical Evaluation Sumary .

I

! In sumary, NRR's technical evaluation shows that between September 30, 1978 l and March 28, 1979, 111 of the 161 tests (69%) included actions that were contrary to the requirements of the Technical Specifications and the precau-

! tiens, limitations, and requirements of Surveillance Procedure 2301-301.

i These actions included unsigned and unapproved test results' greater than the technical specification limit, tests conducted during unstable plant con-

ditions, fests conducted with unreliable or inaccurate instrumentation i providing input to the plant computer, tests conducted during f6ed and bleed operations or tests that contained water additions that were not accounted

{ for in the leak rate calculations, tests that contained water additions that

were affected by MUT level instrument inaccuracies, and tests where hydrogen .

l was added to the MUT while the test was being conducted. T-l I

l

?

4 FINDINGS AND CONCLUSIONS ,

(1) Although leak rate tests were required to be perfomed oriTy o ce every  !

72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />,-leak rate tests were routinely conducted every shift, provided

~

j the plant computer was available and other shift evolutions did not

interfere with the performance of the test.

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

I (3) Most operators had little confidence in the leak rate test that as used to demonstrate conformance with the Technical Specifications. They did ,

not believe that test results were closely coupled with actual plant

}. 1eakage. _

l I (4) Because of the variability of test results, it was common practice to-  !

I run leak rate tests severt.1 times per shift until an acceptable result 1 was obtained. Test resul*:s freopently shwed unidentified leakage in .

e. excess of the technical specification limit of I gpe. The acceptable i

, tests would be retained and, contrary to Technical Specification 6.10 j the unacceptable tests would be discarded. Some tests were discarded by

the CR0s performing the tests and others were discarded by shift foremen  !

l and shift supervisors. l (5) Contrary to Administrative Procedure 1012, tests that exceeded the limits of the Technical Specifications were not logged in the Control  ;

i Room Log. While five of the six shifts routinely logged satisfactory tests, one shift (shift A) did not log any leak rate tests.

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

. completed for tests where the results exceeded the acceptance criteria 7

c. ,

. of the test.

l (7) " Contrary to Technical Specification 3.4.6.2 and Surveillance Procedure i . 2301-3D1, operators did not enter Action Statement 3.4.6.2.b when leak  !

i rate test results indicated unidentified leakage in excess of 1 gpm.  !

l (8) Most operators testified that because the-Technical Specifications only

! required the test to be performed.once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, as long as a

! satisfactory test was obtained during that period, they considered the 4

technical specification satisfied regardless of the number of i

i. unsatisfactory test results that were obtained in between.

(9) During a routine inspection of TMI-2 operations on October 18, 1978, an i NRC inspector discovered several unsigned, unapproved leak rate tests l.

lying in the control room. These tests indicated that TMi-2 had been 4 -:.

l l 1

l

t i

I 1 operating for an extended period with unidentified leakage in excess of 1 gpm without entering the action statement. The ir.cident resulted in Licensee Event Report (LER) 78-62/1T being submitted on November 1,

! 1978. The LER stated that the incident had occurred as the result of a

" misinterpretation" of the requirements of the Technical Speiifications .

i and that appropriate personnel would be instructed on the requirements l

l of the applicable sections of the Technical Specifications and the requirement to innediately invoke applicable action statements when the i l l j provisions of the LC0 were not met.

i. (10) Despite the circulation of the LER to control room personnel and the .

issuance of a " Supervisor of Operations Memo" addressing the subject, l- j l

the majority of the operators testified that leak rate test practices i

did not change. Tests exceeding the limits of the Technical Speci- i j

fications continued to be discarded, and the action statement of the j _ .

Technical Specifications was not invoked. _

(11) Following this incident, some operators testified that they were in-structed to ensure unacceptable leak rate tests were discarded and not ,

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

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

(12) Because of errors in the procedure and an increase in identified leakage l l

l during the months of February and March 1979, it became more and more l I difficult for operators to get leak rate tests results of less than  :

1 gpm for unidentified leakage. The increased identified leakage to the  !

1 i

reactor coolant drain tank was caused by leakage through the P0RY and/or i code safety valves. Identified leakage during this period did not  :

exceed the 10 gpm technical specification limit. .

(

r (13) While some operators testified that they felt pressured to obtain a l

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

of the operators testified that they were never directed by shift i foremen or shift supervisors to manipulate test results. i

\

} (14) Based upon the majority of the operators' testimony, first line super- I vision (shift foremen and shift supervisors) and middle level management I

! (Supervisor of Operations) were aware of the difficulty operators were i experiencing to obtain acceptable leak rate test results. One shift

foreman believed that higher levels of management knew about these pro-l blems, but he could not provide evidence to support his belief.

• 1 (15) CR0s on three of the six shifts (C, D, and E) testified that they were j aware that hydrogen additions to the MUT could influence leak rate test i

results and that they personally added hydrogen to manipulate test results. There is strong evidence to indicate that operators on shift 8 also added hydrogen for this purpose. There is. insufficient evidence to

! conclude that operators on shifts A and F were aware of the; hydrogen effect or used.this method to manipulate test results.

i l

1

- -. - ~_--_m - - -~n.-- ,-

11 i

O -

(16) Operators on shifts D and E also testified that they used water addi-tions to influence the outcome of leak rate tests. An operator on Shift E stated that water was added in small, undetectable amountrbver the period of the test. An operator on shift D stated that he took advan-4 tage of MUT-level transmitter errors while making water additions to i

manipulate test results. On the basis of operator testimony and the l

results of the technical evaluation, there is strong evidence to indi-cate that the other operators on shifts D and E also participated in l

these practices. There is insufficient evidence to conclude that operators on shifts A, B, C, and F used water additions to manipulate l

j test results.

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

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

! such practices on their shifts.

1- (18) On the basis of the technical evaluation, many other tests, involving i

all six shifts, are considered invalid as a result of unaccounted-for 1

feed and bleed operations, unstable plant conditions, and the use of l

inaccurate and unreliable instrumentation to provide input to the plant j computer during the tests. There is insufficient evidence to prove In

- these methods were intentionally used to manipulate test results.

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

conditions for performing the tests. As long as the test result was below thn technical specification limit, the test was signed by the l - . .

operator performing the test and approved by the shift foreman with little or no review.

l"~ In sumary, it is apparent from the technical evaluation and operator testimony that many of the practices associated with the performance of leak l rate surveillance tests at THI-2 violated the Technical Specifications and.

! l approved plant procedures. It is clear also that management's standards for 1 procedural compliance in this area were lax and pemissive. This attitude toward procedural compliance was created by supervisory and management personnel.

The leak rate surveillance test was the only method operators had to measure l

!. unidentified leakage in order to demonstrate compliance with the Technical Specifications. Because of the variability of the test results, most l operators did not consider the test to be a true measure of actual plant i

1eakage. Based on postaccident analysis of the leak rate test procedure, the l operators were correct. The staff believes that many instances occurred where leak rate test results were in excess of the technical specification limit, yet, the actual unidentified leakage did not exceed I gpm. "

. O .

1  :

\

On the basis of operator testimony, when leak rate. test results exc'eeded the technical specification limits, a conscious decision was made by' shift supervisors, and possibly management personnel, to disregard the requirements of the Technical Specifications. While direct leak rate manipulation did occur on some shifts, it is apparent that all shifts performe,d the test with

~

little regard for its validity. If test results exceeded the technical specification limit, they were oiscarded and arother test conducted. If test results were below the technical specification limit, they were retained to satisfy the " administrative requirement." These test results received little or no review, regardless of the plant conditions or evolutions in progress that may have rendered the test invalid. These actions, coupled with the lack of confidence in the leak rate test procedure and management's failure to correct test procedure problems and instill high standards for procedural compliance, led to conditions where leak rate tests were conducted in a frivolous manner and where operators were motivated, in some cases, to manipulate or falsify leak rate test results. -

- l I

l e

1 1

-6 S , W 6

4*

e ,

e 4

O ENCLOSURE 2 CONCLUSIONS AND RECOMMENDATIONS ON CURRENTLY LICENSED INDIVIDUALS Individual Report Date ,

h 800HER, Raymond R December 14, 1984 'Y 1 May 30, 1985 3 CONGDON, Joseph R.

COOPER, Martin V. December 3, 1984 5 October 15, 1985 (Supplement)

Msy 30, 1985 7 FAUST, Craig C.

..[

FREDERICK, Edward R. May 30, 1985 9

~

October 8, 1985 11 GUTHRIE, Carl L.

ILLJES, Theodore F. August 20, 1985 13 4

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

~

September 6, 1985 17

MILLER, Adam W.

~

OLSON, Dennis I. December 14, 1984 20 i

• Recently resigned.

i l NOTE: This enclosure discusses information that is the subject of an ongoing 01 investigation and information that is maintained in the NRC s Privacy Act System of Records (NRC-16). This enclosure may not

)

be disseminated outside the NRC without coordination with NRR and the

permission of the EDO or the Director 01. Internal access and distrib'ution should be on a "need-to-know" basis.

~

i .

1

__. .___.__.__. _______ ._ _______-._~..., ,._ _ , ~__ _ _ _ _

I  !

j

! _I_

! l RAYMOND R. B00HER ,

Current Position: No longer licensed. Mr. Booher resigned f 6 Louisiana

! Power and Light Company on July 26, 1985. Before.his resignation, ' ~

Mr. Booher was a Control Room Supervisor (SRO) at Waterford Unit 3.

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

l 4

Other Individuals on Same Shift at TMI-2:

Shif t Supervisor: Bernie Smith l Shift Foreman: Ken Hoyt ,

Control Room Operators: Harold Hartman i John Blessing (in training)

- Past Involvement in Leak Rate Testing Irregularities:

j . During the period under investigation, Mr. Booher was involved in actions ,

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

_1- Tech.ical Specifications. These actions included: failure to ensure that

leak rate surveillance tests were conducted in accordance with the approved l plant procedures; failure to properly review the results of leak rate '

surveillance tests; failure to properly record all leak rate tests in the l Control Room Log; failure to take the required followup action when the ,

limiting conditions for operation, specified in the Technical Specifications, l

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

~

I '

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

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

l -

j Current Performance:

i l

3 1

1 l

i

t f

l RAYMOND R. B00HER (CONTINUED)

NRR Conclusions and Recomendation: ,

i i 1 l

i l

1 l

k + l f

i i -

! ~

l -_

Stier Report

Conclusions:

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

1 .

i .

4 1 e e

! (.

1 e I

e e

4 b '

4 6

d 4

1. • q l

I #

i r

- , , . - - - - w,.-,-e--, ---- - ,r n -. n,---,v-.. --., - ,,---en ~~A-~~--

l O JOSEPH R. CONGDON i

Current Position: Shift Foreman (SRO). TMI-2. - l Preaccident Position at THI-2: Control Room Operator (RO) on Shift "C."

Other Individuals on Same Shift at TMI-2:

Shift Supervisor: Brian Mehler Shift Foreman: Chuck Adams Control Room Operators: Marty Cooper Mark Phillippe (in training)

Past involvement in Leak Rate Testing Irregularities:

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

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

Technical Specifications. These actions included: failure to ensure that

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

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

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

- influencing test results. It is apparent from Mr. Congdon's testimony that~

he lied 1out his involvement in leak rate test manipulation during a polygrapn test administered by the FBI in October 1980 and possibly in his testimony before the Federal Grand Jury.

1 I

Current Performance:

O

-. . - _~ - - - . . . _. - -- -

i

- 4-1 JOSEPHR.CONGDON(CONTINUED)

Current Performance (continued):

~

NRR Conclusions and-R(commendation:

1

=

d u

(, . Stier Report

Conclusions:

7 i

, . l Analysis of employee testimony, leak rate tests, and related plant documents i

l suggests that'Mr. Congdon failed to properly utilize the leak rate test for  :

j the purpose of measuring reactor coolant system (RCS) leakage and also failed  !

- to take required action in response to indications of excessive RCS leakage in October 1978 and January and March 1979.

Mr. Congdon himself admitted that he knowingly ' engaged in the manipulation of leak rate tests while performing as a CR0 at THI-2 by adding hydrogen to the makeup tank. Furthermore, his testimony, together with plant records,  ;

implicates others on his shift in the same practice. t 9

O

~

I I

t

. , - - . ,- -w

• -- ,.. . . ~ -- , . - . .--.... e mn, --.,, , . . , - ,..-,,v-- - -,.n.. , - - - ,, , , - , , ,- - - -- -n-r,. -- ,- - - - - , , - , -av,,,r- -

I .

i MARTIN V. LOOPER .

Current Position: Control Room Supervisor (SRO), San Onofre Units 2/3.e Control Room Opera.t or (RO) on '_ Shift "C."

Preaccident Position at TMI-2:

l 3f Other Individuals on Same Shift at TMI-2:

Shift Supervisor: Brian Mehler Shift Foreman: Chuck Adams Control Room Operators: Joseph Congdon Mark Phillippe (in training) 9 Past Involvement in Leak Rate Testing Irregularities:

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

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

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

-~

surveillance tests; failure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the limiting conditions for operation, specified in the Technical Specifications,

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

I - Mr. Cooper admitted adding hydrogen to the makeup tank during leak rate tests; however, he denied that is was done with the intent of manipulating the outcome of the test. According to Mr. Cooper, if hydrogen pressure was low in the operating band during periods in which leak rate surveillance tests were being run, he would add hydrogen. If the test results were acceptable, Mr. Cooper would retain the test kncc.fing its results may have ,

been influenced by the addition of hydrogen. Despite Mr. Cooper's denial

~

~

that he intentionally manipulated leak rate tests, the weight of the evidence, including technical evaluation of leak rate tests conducted by Mr.

Cooper and the testimony of Mr. Congdon, strongly suggests that Mr. Cooper '

was involved in intentional manipulation of leak rate tests by adding 4 - hydrogen to the makeup tank.

Current Performance: ,

)

1

- , . . ,v, . -~,,.--~9 . , - . , , , . , , , , - , , . . -- ..--..,-,-,,_,---,..,,,,-....-m.. ,,

- 6-MARTIN V. COOPER (CONTINUED) .

t .

Current Perfomance (continued):

i NRR Conclusions and Recommendation:

i .

- =. ,

i 4  :

. - . Stier Report

Conclusions:

i -

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

i 1

k

, l O

e 4 *e e

d

.r .--..- . _ - _ -- - _ . - _ , , - .,.-,,_,m. _ , _ _ ~ _w....,,,_..,,em,._,m d.,,.. r u. ..,'-

- ,,.m_,,.,,.

O CRAIG C. FAUST .

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

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

Other Individuals on Same Shift at TMI-2:

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

During the period under investigation, Mr. Faust was involved in actions th_at violated approved plant procedures and were contrary to the TMI-2 Technical Specifications. These actions included: failure to ensure that leak rate surveillance tests were conducted in accordance with the approved plant

_ procedures; failure to properly review the results of leak rate surveillance

=-

tests; failure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the limiting conditions for operation, specified in the Technical Specifications, were exceeded; and O failure to retain test results that exceeded the limits of the Technical Specifications.

l Mr. Faust denied that he personally attempted to influence or manipulate the outcome of leak rate test results by the addition of water and/or hydrogen to the. makeup tank during the tests. Mr. Faust also denied that he had personal

- knowledge of, or was aware of other operators intentionally manipulating leak -

rate surveillance tests. While some of Mr. Faust's actions regarding the conduct of leak rate surveillance testing were contrary to the Technical SpectH eations and written procedures, the technical analysis of leak rate 1

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

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

1 Current Performance: 1 1

1 O

__.________.__.__..___.__.____.__,__.f.___.._________,_.__,__..,. ____..__~_,_.a.._,__.,_

CRAIG C. FAUST (CONTINUED)

NRR Conclusions and Recommendation: -~;

Mr. Faust has admitted he was involved in some activities associated with i leak rate testing which were contra'ry to approved ~ plant proced'ufes and technical specifications. However, he denies that he was invol~ved in leak rate test manipulation or had knowledge that such actions occurred. The technical evaluation of leak rate tests involving Mr. Faust tends to support his statement that he was not personally involved in leak rate test falsification. Based on the consistency of his testimony with subsequent technical evaluation and plant records, his statements concerning lack of knowledge of other operators' actions to influence leak rate testing is credible.

..4, O

Stier Report

Conclusions:

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

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

me e

6-

~ ~ -

- , , - - , - , - - , , , , , , , , , - ,.--- w ,, ,,, vnm--_n_,------,cm- - - , - , --------,,m,,--,-m,,-,w,,- ,,vn-,

EDWARD R. FREDERICK 1

Current Position: Instructor V, Corporate Training Division,JsPU Nuclear Corporation. Holds an SRO license on TMI-2.

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

Other Individuals on Same Shift at TMI-2:

Shift Supervisor: William Zewe Shift Foreman: Fred Scheimann Control Room Operator: Craig Faust Past Involvement in Leak Rate Testing Irregularities:

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

Technical Specifications. These actions included: failure to ensure that leak rate surveillance tests were conducted in accordance with the approved

-T. plant procedures; failure to properly review the results of leak rate surveillance tests; failure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the limiting conditions for operation, specified in the Technical Specifications, O were exceeded; and failure to retain test results that exceeded the limits of the Technical Specifications.

The technical analysis tends to support Mr. Frederick's testimony that he did not intentionally add water and/or hydrogen to the makeup tank during leak

- rate tests for the purpose of manipulating test results. However, other aspects of his testimony dealing with difficulty in obtaining satisfactory ,

test results, the disposition of unsatisfactory results, and his overall knowledge of leak rate testing irregularities raise questions regarding the accuracy of his responses during the interview.

t. _-

Current Performance: .

G O -

l

t EDWARD R. FREDERICK (CONTINUED) .

NRR Conclusions and Recommendation:

During the period Mr. Frederick was a licensed control room operator at TMI-2  !

before the accident, he stated that he was neither involved in.~ nor had knowledge of, leak rate testing practices that were contrary to approved plant procedures and Technical Specifications. Mr. Frederick also denied that he was involved in leak rate test manipulation or that he had knowledge  ;

of such actions. While the technical analysis tends to support his testimony that he did not intentionally add water and/or hydrogen to the makeup tank I during leak rate tests for the purpose of manipulating test results, other aspects of his testimony dealing with the difficulty in obtaining satis-factory test results, the disposition of unsatisfactory results, and his overall knowledge of leak rate testing irregularities raise questions re-garding the accuracy of some of his responses during the interview.

~

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

concluded that he was not personally involved in leak rate surveillance test manipulation or falsification.

~

1 u -'-

- Stier Report

Conclusions:

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

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

e

l -11 i CARL-L. GUTHRIE .

Current Dosition: Foreman, Radwaste Operations TMI-2. Holds,an SRO license on TMI-Z.

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

Other Individual on Same Shift at TMI-2:

Shift Supervisor: Ken Bryan Control Room Operators: Hugh McGovern Earl Hemmila Leonard Germer (in training) 1 Past Involvement in Leak Rate Testing Irregularities:

4 During the period under investigation, Mr. G1thrie was involved in actions [

as a Shift Foreman that violated approved plant procedures and were contrary

- to the TMI-2 Technical Specifications. These actions included: failure to ensure that leak rate surveillance tests were conducted in accordance with

- the approved plant procedures; failure to ensure that all leak rate tests were properly recorded by control room operators in the Control Room Log; failure to properly review the results of leak rate surveillance tests; fail-ure to retain leak rate test results that exceeded the limiting conditions of i operation of the Technical Specifications; and failure to take the required -

followup action when the limiting conditions for operation, specified in the

~

Technical Specifications, were exceeded.

Despite these actions, Mr. Guthrie denies that he was involved in or was

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

Current Performance:

].

i .

I O .

(

' l CARLL.GUTHRIE(CONTINUED) ,

1 NRR Conclusions and Recommendation: ,,

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

S i

7 '_

l O

Stier Report

Conclusions:

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

- rate tests and also failed to ensure that required action was taken in response to indications of reactor coolant system leakage during October 1978

- and March 1979. There is insufficient evidence to support a conclusion that i Mr. Guthrie participated in, or knowingly tolerated, manipulation of leak rate test results. .

O em M

(-

THEODORE F. ILLJES I

Current Position: ShiftSupervisorTMI-2(SRO). t l

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

.g

~

Other Individuals on Same Shift at TMI-2: i l

Shift Supervisor: Joe Chwastyk Shift Foreman: Bill Conaway Control Room Operators: John Kidwell

- Chuck Hell (in training) 1 Past Involvement in Leak Rate Testing Irregularities:

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

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

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

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

- -Z. surveillance tests; failure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the limiting conditions for operation, specified in the Technical Specifications, i were exceeded; and failure to retain test results that exceeded the limits of O the Technical Specifications.

Mr. Illjes denies that he perfomed evolutions with the intent of influencing l the outcome of leak rate test results. Based on the weight of the available evidence, including the high number of invalid or questionable tests ,

involving Mr. Illjes and the testimony of his former Shift Supervisor 1 (Mr. Chwastyk), it appears that either Mr. Illjes was not truthful regarding i his knowledge of or involvement in leak rate test manipulation, or he was l grossly negligent in that he would knowingly accept test results less than

,- th.e technical specification limit regardless of the evolutions in progress I -

during the test.

Current Performance:

I e

l O .

4

-___-----,-,----------nu--nn. . . -_a.,,_---nme-nn-w,,_n- ,-_.,.e-ww,,,,._,-w-aw,,n p>,,.,~,-,aw,.--,n-en..

i THEODORE F. ILLJES (CONTINUED)

Current Perfonnance (continued):

1 NRR Conclusions and Recomendation:

During the period Mr. Illjes was licensed as a control room operator at TMI-2 before the accident, he admitted he was involved in activities associated with reactor coolant system leak rate testing that were in violation of

- . approved plant procedures and the TMI-2 Technical Specifications. However-he denies that he was involved in leak rate test manipulation or knowledgeof such actions. The weight of available evidence, including statements by his former Shift Supervisor (Mr. Chwastyk) and the technical analysis, strongly 7.- suggests that Mr. Illjes was either not truthful in answering questions regarding his role in, or knowledge of, leak rate test manipulation, or he '

was grossly negligent in performing leak rate tests.

In sumary, while the accuracy of some of Mr. Illjes' statements regarding a leak rate testing irregularities is suspect, NRR was unable to prove that he lied, NRR concluded that he may have been involved "

in,

~"

or had knowledge of

. leak rate test, manipul,ation.

Stier Report

Conclusions:

Analysis of eaployee testimony, leak rate test records, and related plant documents indicates that Mr. Illjes did not properly utilize taak rate tests for the purpose of measuring reactor coolant system leakage an.d did not take required action in response to the indications of excessive lea'kage. There also is strong circumstantial evidence that Mr. Illjes knowingly added hydrogen during leak rate tests in order to manipulate test results.

HUGH A. MCGOVERN JR.

l Current Position: Plant Operations Manager TMI-2. Holds an SAO license on i TMI-2. _

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

Other Individuals on Same Shift at TMI-2:

Shift Supervisor: Ken Bryan Shift Foreman: Carl Guthrie Control Room Operators: Earl Hennila Leonard Genner (in training)

I Past Involvement in Leak Rate Testing Irregularities: -

j During the period under investigation, Mr. McGovern was involved in actions

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

- Technical Specifications. These actions included: failure to ensure that 7.- leak rate surveillance tests were conducted in accordance with the approved plant procedures; failure to properly review the results of leak rate surveillance tests; failure to properly record all leak rate tests in the 4

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

the Technical Specifications.

Mr. McGovern agrees in retrospect that many of his actions involving le.ak rate surveillance testing at TMI-2 violated approved plant procedures and were contrary to the TMI-2 Technical Specifications. Because of problems with instrumentation and the procedure itself, Mr. McGovern considered the test " meaningless" as far as representing true plant leakage. As a result,

'_- the test was treated as an administrative requirement only. He denies that he was involved in intentional leak rate test manipulation. From the technical evaluation of leak rate tests involving Mr. McGovern, there is ~ -

insufficient evidence to conclude that any of these tests were intentionally manipulated. However, based on Mr. McGovern's attitude towards the test at the time, it appears he did not attempt to establish the proper steady-state conditions required for the test. If the test result was greater than the technical specification limit, the test would be discarded and.another test would be started. If the test result was less than the technical specifi- .

cation limit, he would retain it with little or no review to ensure it was a I valid test. l

. I Current Performance: l

O HUGH A. MCGOVERN JR. (CONTINUED)

Current Performance (continued): .

NRR Conclusions and Recomendation: '

During the period under investigation, Mr. McGovern admitted be was involve

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

were in, violation of approved plant procedures and the TMI-2 Technical Specifications. Despite these actions, Mr. McGovern denies that he was involved in or was knowledgeable of, any activities on the part other CR0s to intentionally influence or manipulate the outcome of leak rate test results.

T--

There is insufficient evidence to conclude that Mr. McGovern was involved leak rate test manipulation; however, the evidence supports a finding that Mr. McGovern was grossly negligent in his duties as a control on hisroom operator O with respect to leak rate surveillance testing.

Based stated that the test was a meaningless administrative requirement that bore little opinion resemblance to actual plant leakage. NRR concludes he submitted test results without regard for their validity, as long as the calculated unidentified leakage ,as below the technical specification limit.

k.

i I

~

Stier Report

Conclusions:

Analysis of employe'e testimony, leak rate test records, ard related plant documents suggests that Mr. McGovern failed to properly utilize leak rate tests for the purpose of measuring reactor coolant system leakage and also O- failed to take required action in response to the indications of excessive reactor coolant system leakage in' March of 1979. There is not sufficient evidence to support a conclusion that Mr. McGovern knowingly added water or hydrogen during leak rate tests in order to manipulate test results.

ADAM W. MILLER He holds an SRO license Current Position: Manager Plant Operations TMI-2. "

on THI-Z.

Preaccident Position at THI-2:

ShiftForeman(SRO)onShift"Dif Other Individuals on Same Shift at TMI-2:

Shift Supervisor: Greg Hitz Control Room Operators: Dennis Olson Mark Coleman Lynn Wright Past Involvement in Leak Rate Testing Irregularities:

i

.During the period under investigation, Mr. Miller was involved These actions included: failure to to the THI-2 Technical Specifications.

ensure that leak rate surveillance tests were conducted in accordance the approved plant procedures; failure to ensure that all leak rate tests 2- were properly recorded by control room operators in the Control Room Log; failure to properly review the results of leak rate surveillance tests; failure to retain leak rate test results that exceeded the limitin O the required followup action when the limiting conditions for operation, specified in the Technical Specifications, were exceeded.

Mr. Miller agrees in retrospect that many of the actions involving leak rate l

- surveillance testing at TMI-2 violated approved Mr.plant procedures Miller andthat was aware were as l

~

contrary to the TMI-2 Technical Specifications. Shift Foreman it was h Mr. Miller also agrees that there is strong the Technical Specifications.

evidence, including the testimony of Mr. Coleman, to indicate operators on his shift were performing actions that were contrary to int with the intent of influencing or manipulating the outcome of leak rate surveillance tests.

he had little involvement ir the performance of leak rate tests and had no involvement in or knowledge of operators on his shift. intentionally manipulating the outcome of test results.

The results of the technical analysis indicate that of the six shifts standing watch during the last 3 months of operation of TMI-2, Shift "D" had The vast the highest percentage (93%) of " questionable" leak rate tests.

majority of these questionable tests show water additions to the makeup tank during the last few minutes of the test, resulting in a calculated leak rateDe that was smalles,than the actual leak rate.

the three CR0s as to why the water additions were made, the we.ight of the evidence would indicate that these additions were made to intentionallyWhile Mr. Mill G influence the outcome of leak rate surveillance tests.

not directly invo,1ved in the actual conduct of the tests and his statements

i I

1

)

O ADAMW. MILLER (CONTINUED)

I l

Past Involvement in Leak Rate Testing Irregularities (continued)i -

l that he did not order or direct the manipulation of tests are credible l and i are supported by the operators' testimony, it does not appear T ausible that j Mr. Miller was unaware that leak rate test manipulations were taking place on l his shift.

Current Performance:

NRR Conclusions and Recommendation:

During the period under investigation, while Mr. Miller served as the Shift Foreman at TMI-2 for Shift "D," he admitted he was involved in activities

.- associated with reactor coolant system leak rate testing that were in violation of approved plant procedures and the TMI-2 Technical Specifications.

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

O

• "'**'*Mv-e'-rww-we.,-,,ee,,. . . , __

ADAM W., MILLER .

1 NRR Conclusions and Recomendation (continued): ,

Stier Report

Conclusions:

Analysis of employee testimony, leak rate test records, and related plant documents reveals that Mr. Miller failed to properly supervise the -

perfomance of leak rate tests and also failed to ensure that required action was taken in response to indications of reactor coolant system leakage during October 1978 and January 1979. There is insufficient evidence from which

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

manipulation of leak rate test results.

i e

e M

~

-r--r- ----'cet rwewrwg--w-rp- 9 - -w- erve- * - y- r v t--wew tw egwww_ Te- er***-t-e w w-t M-e- tv e rw--W 7-m--r--+-w*wwwww-everww-eF-a--frtv-v-t--ww--1m-

DENNIS 1. OLSON Current Position: No longer licensed. Mr. Olson resigned from Louisiana Power and Light Company on June 28, 1985. Prior to his resignution, Mr. Olson was a Control Room Supervisor (SRO) at Waterford Uni _t.3.

Preaccident Position at TMI-2: Control Room Operator (RO) on $~hift "D."

Other Individuals on Same Shift at TMI-2:

Shift Supervisor: Greg Hitz Shift Foreman: Adam Miller Control Room Operators: Mark Coleman Lynn Wright Past Involvement in Leak Rate Testing Irregularities:

During the period under investigation, Mr. Olson was involved in actions -that

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

__. Specifications. These actions included: failure to ensure that leak rate

.1- surveillance tests were conducted in accordance with the approved plant procedures; failure to properly review the results of leak rate surveillance tests; failure to properly record all leak rate tests in the Control Room Log; failure to take the required followup action when the limiting con-O, ditions for operation, specified in the Technical Specifications, were exceeded; and failure to retain test results that exceeded the limits of the

. Technical Specifications.

Throughout the interview Mr. Olson did not appear to answer key questions in

~.. a straightforward or candid manner. The majority of his responses concerning the conduct of leak rate surveillance tests after the October 18, 1978 inci-dent resulting in LER 78-62/1T are inconsistent with the testimony of his Shift Foreman and the other CR0s on his shift. In addition, his denials that

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

outcome of leak rate tests. The technical evaluation of leak rate tests performed on shift "D" supports Mr. Coleman's testimony and not Mr. Olson's.

Current Performance:

O O

1 l

l l l DENNIS 1.OLSON(CONTINUED) .

~

Current Perfomance (continued): e

.Q..._

O NRR Conclusions and Recomendation: -

!:- During the period that Mr. Olson was licensed as a Control Room Operator at i TMI-2 before the accident, he admitted he was involved in some activities i associated with leak rate testing irregularities until the October 18, 1978

'- LER incident. However, after this date, he denies that he was involved in g- leak rate test irregularities, including test manipulation or falsification.

! The weight of evidence, including statements by Mr. Coleman and the results

! of the technical evaluation of Mr. 01 son's leak rate tests, strongly suggests

l. that Mr. Olson was not truthful in answering questions regarding his role in leak rate test manipulation. The specific areas where Mr. 01 son's version of the facts differ from other evidence are:

~

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

~

DENNIS I. OLSON NRR Conclusions and Recom.endation (continued): -

~

R. ._

Stier Report

Conclusions:

The Stier Report does not reach conclusions regarding Mr. Olson because he is

! not longer employed within the GPU system.

O no 4*

i 4

s ~

i O

w e

& eO e

_ __