ML20203C003
| ML20203C003 | |
| Person / Time | |
|---|---|
| Site: | Crystal River  |
| Issue date: | 03/12/1996 |
| From: | Gibson A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Curtis Rapp NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| Shared Package | |
| ML20203B366 | List: |
| References | |
| FOIA-97-313 NUDOCS 9712150203 | |
| Download: ML20203C003 (26) | |
Text
- - . _ . . . . . _ . . _ _ . . . . ..l March 12, 1996 f i
(
MEMORANDUM TO: Curtis W. Rapp, Reactor Engineer .
Division of Reactor Safety FROM: Albert F. Gibson, Director (ORIGINAL SIGNED BY :
Division of Reactor Safety ALBERT F. GIBSON) i
SUBJECT:
YOUR CONCURRENCE ON CRYSTAL RIVER INSPECTION REPORT 95-22 :
Jon Johnson informed me yesterday that you said that you did not concur with
- the findings in Crystal River Inspection Report 95-22. I was not awar,e of this disagreement. Based upon your written concurrence and discussions that i we have had on these matters, I thought that you agreed with the findings 4 regarding operator performance and with the apparent violations identified in
-this report. .
Please provide a-written response to this memo specifically describing how your personal views differ from the findings _and apparent violations described in report 95-22. I have attached a draft notice of violation, based in part on the findings in report 95-22, which will serve as a basis for discussions during upcoming enforcement conference with Crystal River operators. I understand that you have reviewed this notice of violation and that your -
comments have been incorporated. In response to this memo, please state whether or not you concur with this draft notice of violation and the basis for any disagreement you may have. Please respond before next Thursday, March 21, 1996, so that your comments can be considered during the enforcement conference planning meeting scheduled for that date.
Attachment : Draft Notice of Violation Distribution: -
S. Ebneter, RA w/att M ohnson, DRP w/att r
i Sf MD TO 8*Ld! t? DoctrvfNT POOM' YES h.N . _ .
l Of flCE filt.Ok SIGN AT URE NAME AGabson:obw DATE 014 b o 03I I96 03I' I98 031 196 031 196 03 I I96 COPYF [EES / . NO YEs NO YES NO YES NO YES NO YES NO Of f lCI A1,46eostD COPT DOCUME N T k AME t Gl \ MEMO \DD\t APP.4 9712150203 971203 ATTACHMENT 9 PDR FOIA .
PDR -I p gy ,LIAW97-313
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50 . 5 9 c j%eM- '
DRAFT NOV FOR CRYSTAL RIVER OPERATORS
- _] issued on (_DATE ] to [ NAME_] required, in part, that License while per [Ter(m)ing licensed duties, (RKME] shat 1 observe the operating '
procedures and other condition', specified in the facility license which authorizes operation of the facility.
Condition 1.C of the Crystal River Unit 3 Operating License No. DPR-72 requires the facility to be operated in conformity with the application, as amended, the provisions of the Act, and the rules and-regulations of the Comission.
10 CFR 50.59, Changes, Tests, and Experiments, in part, allows the licensed facility to conduct tests not described in the safety analysis report (SAR),
unless the proposed test involves an unreviewed safety question. A proposed test shall be deemed to involve an unreviewed safety question if the probability of occurrence or the consequences of an accident or malfunction of equipment important to safety previously evaluated in the SAR may be '
increased. The licensee shall maintain records of tests carried out pursuant ,
to this section, including a written safety evaluation which provides the basis for the determination that the test does not involve an unreviewed safety question.
Crystal River 3 Technical Specification 5.6.1.1 requires, in part, that procedures be implemented covering activities as recommended in Regulatory Guide 1.33, Revision 2, Appendix A, of February 1978. Appendix A recommends procedures for operation of the reactor coolant system makeup sys, tem.
Crystal River 3 procedure Al-500, Conduct of Operations, Rev. 80, stated that it is the duty of every member of the Crystal River Plant work force to comply with procedures. Procedure OP 402, Makeup and Purification System, Rev. ??,
required that operators ensure that the make-up tank pressure limits of OP-103B, Curve 8, are not exceeded when adding hydrogen to the make-up tank by manually bypassing the 15 psig hydrogen regulator. Procedure OP-103B.
Curve 8, Maximum Make-up Tank Overpressure, Rev.12, defined the acceptable make,-up tank pressure versus level operating region. Procedure AR-403, PSA H Annunciator Response, Rev. 22, required operators to take action to reduce make-up tank pressure to within t'u limits of OP-103B, Curve 8, when a valid alarm is received.
Contrary to the above, on September 4 and 5, 1994, [ NAME ) deliberately violated Crystal River 3 procedures and other conditions specified in the facility license which authorizes operation of the facility when (HE, SHE]
conducted tests not described in the SAR, without written safety evaluations ,
which provided the basis for the determination that the tests did not involve an unreviewed safety question. Specifically, [NAME] conducted tests, not required by plant conditions, to collect data involving reactor coolant sysytes sake-up-tank pressure and level . During the tests,' (NAME) failed to meet the requirements of Al-500 to comply with the following Crystal River 3 procedures:
- a. OP-402, Step ???l was not met on September 4 and 5,1994, in that the make-up tank pressure exceeded the limits of OP-103B, Curve 8, while Attachment
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adding hydrogen to the make-up tank by manually bypassing the 15 psig ,
hydrogen regulator.
- b. The limits of OP-103B on acceptable make-up tank pressure were exceeded on September 4,1994, for approximately 43 minutes, from approximately !
4:24 a.m. to 5:06 a.m. and on September 5, 1994 for approximately 37 minutes continuously from approximately 4:45 a.m. to 5:21 a.m.
- c. AR-403, Step ???, was not met on September 4 and 5,1994, in that timely action was not taken to reduce make-up tank pressure to within the limits of OP-103B, Curve 8, when a valid alarm was received.
BACKGROUND ,
Unreviewed Safety Ouestion ,
i The test did involve an unreviewed safety question in that maKe-up tank design basis limits of OP-103B, Curve 8, were exceeded. Curve 8 had been calculated to provide a margin of about 0.8 pounds per square inch (psig) to prevent potential-make-up pump gas binding during an accident. The September 4 test exceeded Curve' 8 limits by as much as 2.36 psig. The September 5 test
. exceeded Curve 8 limits by as much as 1.71 psig. Under these conditions, one postulated accident scenario, a loss of Coolant Accident with a core flood line break and a concur ent emergency diesel generator failure, could result in the loss of all high pressure and low pressure injection flow to. the nuclear reactor.
Alarm Response ;
With regard to the alarm response, Curve 8 was exceeded, and the alarm was in, for approximately 43 minutes on September 4 and 37 minutes on September 5, continuously. In response to the. alarm, instead of reducing make-up tank
-pressure to within the limits of Curve 8, the operators lowered mate-up tank level which caused make-up tank pressure to exceed Curve 8 by an increasing amount.
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2N90 DRAFT f40V FOR CRYSTAL RIVER OPERATORS to ( NAME_) required that while ;
(_ (#) _) issued on [LRE, DATE License performing licensed duties, SHfl)shall_ observe the operating procedures I and other conditions specified in the facility license which authorizes )
operation of the facility.
10 CFR 50.5, Deliberate Misconduct, in part, prohibits facility licensee employees from engaging in deliberate mi conduct that causes a licensee to be in violation of a condition of any license issued by the Comission.
Deliberate misconduct is defined as an intentional act or omission that the person knows would cause a licensee to be in violation of any regulation issued by the Commission or that constitutes a violation of a procedure of a licensee.
10 CFR 50.59; Changes. Tests, and Experiments; in part, allows the licensed facility to conduct tests not described in the safety analysis report (SAH),
unless the proposed test involves an unreviewed safety question. A proposed test shall be deemed to involve an unreviewed safety question if the probability of occurrence or the consequences of an accident or malfunction of equipment important to safety previously evaluated in the 5AR may be increased. The licensee shall maintain records of tests carried out pursuant to this section, including a written safety evaluation which provides the basis for the determinatior that the test does not involve an unreviewed safety question.
Crystal River 3 Technical Specification 5.6.1.1 requires, in part,- that procedures be implemented covering activities as recommended in Regulatory Guide 1.33, Revision 2, Appendix A, of February 1978. Appendix A recommends procedures for cper3 tion of the reactor coolant system makeup system.
Crystal River 3 procedure Al-500, Conduct of Operations, Rev. 80, stated that it is the duty of every member of the Crystal River Plant work force to comply with procedures. Procedure OP-402, Makeup and Purification System, required that operators ensure that the make-up tank pressure limits of OP-1038, Curve 8, ar,e not exceeded when adding hydrogen to the make-up tank by manually bypassing the 15 psig hydrogen regulator. Procedure OP-103B, Curve 8, Maximum Make-up Tank Overpressure, Rev.12, defined the acceptable make-up tank pressure versus level operating region. Procedure AR-403, PSA H Annunciator Response, Rev. 22, required operators to take action to reduce make-up tank pressure to within the limits of OP-103B, Curve 8, when a valid alarm is received.
. Contrary to the above:
- 1. [__NAME - engaged in deliberate misconduct in that (HE, SHE]
intentionaaT)ly caused Crystal River 3 to be in violation of a regulation issued by the Comission when (HE, SHE):
- a. Intentionally violated 10 CFR 50.59 by conducting a test not described in the SAR on September 4,1994, without a written safety evaluation which provided the basis for the determination that the test did not involve an unreviewed safety question. [HE, l
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SHE) conducted a test in that [HE, SHE) conducted an evolution involving make up tank pressure and level, not required by plant ,
conditions, to collect data, and which involved violation of .;
Crystal River 3 procedures. The test did involve an unreviewed safety question in that make-up tank design basis limits of OP-103B, Curve 8, were exceeded. Curve 8 had been calculated to
-provide a margin of about 0.8 psig to prevent potential make-up q pump gas binding during an accident, and the September 4 test ;
exceeded Curve 8 limits by as much as 2.36 psig. Under these l conditions,- one postulated accident scenario, a Loss of Coolant i Accident with a core flood line break and a concurrent emergency !
diesel generator f ailure, could result in the loss of all high pressure and low pre:,sure injection flow to the nuclear reactor.
- b. Intentionally violated 10 CFR 50.59 by conducting a test nt t ,
described in the SAR on September 5, 1994, without a writttn !
safety evaluation which provided the basis for the determinption l that the test did not involve an unreviewed safety question. [HE, SHE) conducted a test in that (HE, SHE) conducted an evolution ,
involving make up tank pressure and level, not required by plant conditions, to collect data, and which involved violation of '
Crystal River 3 procedures. The test did involve an unreviewed safety question in that make-up tank design basis limits of OP- i 103B, Curve 8, were exceeded. Curve 8 had been calculated to ,
provide a margin of about 0.8 psig to prevent potential make-up pump gas binding during an accident, and the September 5 test exceeded Curve 8 limits by as much as 1.71 psig. Under these conditions, one postulated accident scenario, a Loss of Coolant Accident with a core flood line break and a concurrent emergency diesel generator failure, could result in the loss of all high pressure and low pressure injection flow to the nuclear reactor, s
- 2. [ NAME ] engaged in deliberate misconduct in that (HE, SHE) intentionally violated [AND DIRECTED LICENSED OPERATORS TO VIOLATE)
Crystal River 3 procedures AI-500, OP-402, OP-103B, and AR 403 when (HE,
,SHE]:
- a. Intentionally violated OP-402 on September 4,1994, in that (HE, SHE) allowed the make-up tank pressure to exceed the limits of OP-103B, Curve 8 while adding hydrogen to the make-up tank by manually bypassing the 15 psig hydrogen regulator,
- b. Intentionally violated AR-403 on September 4,1994, in that (HE, SHE) failed to take timely action to reduce make-up tank pressure to within the limits of OP-103B, Curve B, when a valid alarm was received. Curve 8 was exceeded, and the alarm was in, for approvimately 43 minutes continuously. In response to the alarm, instead of reducing make-up tank pressure to within the limits of Curve 8, (HE, SHE) lowered make-up tank level which caused make-up
! tank pressure to exceed Curve 8 by an increasing amount.
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- c. Intentionally violated OP-103B on' September 4,1994, in that (HE, SHE) exceeded the limits of Curve 8 on acceptable make-up tank pressure for approximately 43 minutes continuously, from 1
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approximately 4:24 a.m. to 5:06 am.
- d. Intentionally violated OP-402 on September 5,1994, in that [ lie, SliE) allowed the make-up tank pressure to exceed the limits of OP-103B, Curve 8, while adding hydrogen to the make-up tank by manually bypassing the 15 rsig hydrogen regulator,
- e. Intentionally violated AR-403 on September 4,1994, in that [HE, SHE) failed to take timely action to reduce make-up tank pressure to within the limits of OP-103B, Curve 8, when a valid alarm was 1eteived. Curve 8 was exceeded, and the alarm was in, for approximately 37 minutes continuously. In response to the alarm, instead of reducing make-up tank pressure to within the limits of Curve 8. [HE, SHE] lowered make-up tank level which caused make-up tank pressure to exceed Curve 8 by an increasing amount.
- f. Intentionally violated OP-103B on September 4,1994, in that [HE, SHE] exceeded tt a limits of Curve 8 on acceptable make-up tank pressure for approxin.ately 37 minutes continuously, from approximately 4:45 a.m. to 5:21 am.
f
@CJ M yI l% - l Sb, s~4 i DRAFT NOV FOP CRYSTAL RIVER OPERATORS issued on DATE to NAME__) required that while ,
License (J)_,)
performing icensed duties, $,SHU)shalG[bserve the operating procedures i and other conditions specified in the facility license which authorizes operation of the facility. !
Condition 1.C of the Crystal River Unit 3 Operating License No. DPR 72 '
l requires the facility to operate in conformity with the application, as amended, the provisions of the Act, and the rules and regulations of the ,
Commission.
10 CFR 50.59, Changes, Tests, and Experiments, in part, allows the licensed i' facility to conduct tests not described in the safety analysis report (SAR),
unless the aroposed test involves an unreviewed safety question. A proposed test shall >e deemed to involve an unreviewed safety question if the probability of occurrence or the consequences of an accident or malfunction of
- l-equipment important to safety previously evaluated in the SAR may be increased. The licensee shall maintain records of tests carried out pursuant to this section, including a written safety evaluation which provides the basis for the determination that the test does not involve. an unreviewed safety question.
NAME Contrary and other conditions to the above, spe [BTied in the facility license which authorizes) failed operation of the facility when (HE, SHE): ,
- a. Deliberately violated 10 CFR 50.59 by conducting a test not ' described in the SAR on Statember 4,1994, without a written safety evaluation which provided the aasis for the determination that the test did not involve ,
an unreviewed saf ety question. (HE, SHE) conducted a test in that (HE, .
SHE) conducted an evolution involving make-up tank pressure and level, not required by plant conditions, to collect data, and which involved '
violation of Crystal River 3 procedures. The test did involve an unreviewed safety question in that make up tank design basis limits of 0P-103B, Curve 8, were exceeded. Curve 8 had been calculated to provide a cargin of about 0.8 pounds per square inch (psig) to prevent potential make up pump gas binding during an accident, and the September 4 test exceeded Curve 8 limits by as much as 2.36 psig. Under these conditions, one postulated accident scenario, a Loss of Coolant Accident with a core flood line break and a concurrent emergency diesel generator failure, could result in the loss of all high pressure and low pressure injection flow to the nuclear reactor, ,
- b. Deliberately violated 10 CFR 50.59 by conducting a test not described in the SAR on September 5,1994, without a written safety evaluation which provided the basis for the determination that the test did not involve e an unreviewed safety question. (HE, SHE] conducted a test in that (HE,
-SHE) conducted an evolution involving make-up tank pressure and level, not reouired by plant conditions, to :ollect data, and which involved violation of crystal River 3 procedures. The test did involve an unreviewed safety question in that make-up tank design basis limits of OP-103B, Curve 8, were exceeded. Curve 8 had been calculated to provide 4 h
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a margin of abot.t 0.8 psig to prevent potential make-up pump gas binding during an acticent, and the September 5 test exceeded Curve 8 limits by as much as 1.71 psig. Under these conditions, one postulated accident scenario, a loss of Coolant Accident with a core flood line creak and a concurrent emergency diesel generator failure, could result in the loss of all high pressure and low pressure injection flow to the nuclear reactor.
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/U49 UNfTED STATES NUCLEAR REGULATORY COMMCSION ,
,P g$ cEcloN 11 l 101 MARIETTA STREET. N.W.. SUITE 2s00 - i ra 8 ATLANTA, GEoftGIA 3352M190 ;
4,,**"*j March 20, 1996 l
MEMORANDUM TO: Albert F. Gibson, Director !
Division of Reactor Safety !
FROM: Curtis W. Rapp, Senior Reactor Inspector
. Division of Reactor Safety v
SUBJECT:
RESPONSE TO YOUR MARCH 12, 1996 MEMORANDUM CONCERNING {
-PROPOSED NOTICE OF VIOLATION FOR CRYSTAL RIVER OPERATORS e As directed by the above subject memorandum,.I am providing a detailed explanation of my professionai objection-to the proposed. procedural . J violations. However, I take exception to several statements in the subject j memorandum.
Your characterization that I did not concur with IR 95-22 is inaccurate; !
f I did and still do concur with the IR 95-22. What I told Mr. Johnson was that I do not r. gree that procedural violations occurred, but these ,
procedural issues need to be discussed. The enforcement conferences '
with the operators will provide that opportunity. Additionally, bot,h IR 95-22 and the subject memorandum refer to these procedural violations as
" apparent violations." As I understand, this means no-decision has been 1 made to actually cite the operators for these violations. If this !
decision has already been made, I was not included in this process.
You state that you were not aware of my professional objection to these proposed procedural violations. I have expressed my professional objection during meetings on 7/6/95,7/11/95,10/17/95,10/23/95, 12/5/95, 12/20/95, 1/9/96, 1/24/96, and 1/26/96 where either you or In particular, during the other Regional senior managers were present.
meeting on 10/23/95 you said that I may not be the right individual to
' send back to Crystal River with 01 ". . . given my personal views."
Furthermore, I de.cribed my professional objection and associated reasoning in a memorandum to Ellis W. Herschoff dated July 27, 1995 of -
, which you received a copy. .
I did review and comment on the proposed notice of violation (NOV). !
However, again I was excluded when tne proposed NOV was dratted. I i
requested to review the proposed NOV only after being asked specific questions about correct procedural revision numbers. I provided my comment.t to the EICS staff member assigned to the enforcement actions.
-Based on my review of the proposed NOV attached to the subject memorandum,: not all my coments were incorporated. I also requested
~that I be included on distribution for any future revisions to the proposed NOVs. : Only through my efforts have I been afforded the ,
- opportunity to review and coment on the proposed NOV.
1 ATTACHMENT 10 i
_ J_ .
. .u._._-. . __ __ _ . . - ,
A. F. Gibson !
As' stated above, I clearly stated my professional objection to the proposed procedural violations in my. memorandum of July, 27, 1995. A copy is provided es an attachment to this memorandum. However, as directed by the subject ;
memorandum, 1 DO NOT concur with the inclusion of procedural violations in the draft notice of violation.
As stated above, I clearly stated my reasoning why I disagreed with the proposed procedural violations. However, as directed by the subject
- memorandum. I have provided detailed explanations why the proposed procedural
-violations have no merit.
Item a, of the proposed NOV states the operators violated procedure OP-402 by exceeding the allowable pressure limit when adding hydrogen. I .
revimed the plant conditions for September 4 and 5,1994 as described in Ik ?-22 and plotted these conditions on a copy of Curve 8. I found the'make up tank pressure was within the-allowable limit given by Curve 8 on both September 4 and 5, 1994. If the make-up tank pressure limit was exceeded, it was exceeded by substantially less than the 0.5 psig ;
criteria applied to determine if other instances were a violation ,of the allowable pressure limit.
ltem b. of the proposed NOV states the limit on acceptable make-up tank ,
pressure was exceeded for a substantial time on both September 4 and 5, 1994. As stated in my July 27, 1995 memorandum, OP-103B is not a procedure but contains the administrative operating limits. Therefore, exceeding the acceptable make up tank pressure must be cited in the context of a procedural requirement. Procedure OP-402 only referenced this limit when adding hydrogen; not when make-up level was changed.
Also, as identified in IR 95-22, there was no precaution or limitation in OP-402 that references acceptable make-up tank pre:sure limit. Since OP 402 was not violated when make-up tank pressure was increased and maintaining make up pressure was not procedural required when changing
'make-up tank level, OP-402 cannot be used to cite a violation of OP-1038. The only place where compliance with administrative limits is mentioned is Al-500 as an operator responsibility. However, this is not included in the proposed NOV provided with the su.bject memorandum.
Jtem c. of the proposed NOV states the operators did not respond to the alarm as required by AR-403. Al-500 4.3.2.2.4 states:
Annunciator Response Procedures (AR's) shall be utilized as n
follows: .
, 1. Annunciator response procedures shall' be used to
' diagnose alarms not expected (not directly related to intentional manipulation of plant controls), and for any alarm the operators are not explicitly familiar ;
with. (emphasis added) .
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o .
{
?
A. F. Gibson
- 2. The Control Board Operators shall interpret and verify [
that . annunciator alarm signals are consistent with ;
plant conditions.- l Clearly, the administrative guidance to the operators did not require .
any response to the alarm because it resulted directly from the !
manipulation of plant controls. Furthermore, the operators would have :
had contradictory indications (plant computer and control board !
recorder) to determine if the alarm was valid. Because the recorder was the qualified control- room instrument, it would be expected the operators used the recorder to validate the alarm, i No timeliness requirement is present in this procedure and, as !
-documented in IR 95-22, no administrative guidance for timeliness of alarm response existed.,
The control room alarm was driven from a computer algorithm that approximated OP-103B Curve 8. This algorithm did not provide any ,
deadband causing the alarm to activate whenever make-up tank pressure ;
was at or above the limit-given by OP-103B Curve 8. Therefore, activation of the alarm does not indicate the make-up tank allowable l presvare is being exceeded.
You have consistently characterized my professional objection as " personal views." This is not my " personal views," but instead is a professional '
objection arising from both my operational experience at commercial nuclear power plants and facts from my involvement with the OI interviews and on-site !
inspection. Just because my professional objection is in direct opposition to management's desired outcome does not diminish the fact it is indeed professional and not " personal."
Attachments:
Memorandum of July 27, 1995 Comments on proposed NOV cc: ' J. Johnson K. Landis 4
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UNITED STATLS {
_,I**88%4 NUCLEAR REGULATORY COMMISSION !
- "S. REGloN 11 5' 101 MARitTTA STMET, N.W., SUITE 300 E lS ATLANTA, GEORGIA 30ED-019e W**eM/*** Hay 3, 1996 MEMORANDUM TO: Stewart D. Ebneter Regional Administrator
.FRON! Curtis W. Rapp, Rextor Engineer Division of Reactor Safety V
SUBJECT:
DPV PANEL RESUI.IS
.Your memorandum of April 12, 1996, transmitted the results of the management initiated DPV Panel for my memorandum to A. Gibson dated .
february 5, 1996. After reviewing these results, I must take exception to the conclusions reached by the DPV Panel. In general, the responses to my concerns db not address the actual points which I was making, further, a number of statements in the Discussion section of the DPV Panel report are grossly misleading if not factually incorrect.
I wish to reiterate that I did not submit my " lessons learned" as a Differing Professional View but as recommendations to improve NRC processes in the
-future. However, rather than accepting these recommendations in the constructive spirit in which they were offered, NRC management chose.to construe them as adversarial and concentrated on " disproving" my observations.
I see no evidence that the underlying concerns were given due and impartial consideration in a productive manner. Additionally, the manner in which they were handled serves to promote a chilling effect.
The following paragraphs are detailed explanations for my exception to the DPV Panel conclusions.
Lesson 1: Insoect First. Then Investiaate-The DPV Panel did not address the point I was mak .g, which was an apparent weakness in.the. Agency policies and practices pertaining to cases of potential wrongdoing which require both investigation and inspection. I was using my_
experiences with the Crystal River Makeup Tank as an exarhple to point out the consequences of postponing critical inspection activities on the basis of avoiding " compromising the OI investigation of wrongdoing." The DPV Panel's response to my recommendation was to simply reiterate the very guidance and practices which I was questioning. This did nothing to address my concern, and indicated that my recommendation was dismissed without due consideration.
The Discussion contained-an extremely misleading paragraph which indicated that adequate inspection was in fact performed prior to and during the period in which the 01. investigation was ongoing by listing six inspection reports as having been issued " prior to the release of the 01 Investigation Report." The number of inspection reports issued prior to the release of the 01 report is irrelevant end misrepresentative. In fact, only one inspection report, IR 94-22, was issued prior to the'on-site 01 investigation conducted in
S. Ebneter 2 December 1994. This level of inspection was clearly not adequate in that it failed to identify critical information such as the performance of evolution conducted on September 4, 1994 which did not become known to NRC until July 1995. Yet, according to the FPC Internal Investigation report and the 01 interviews, the September 4 evolution was properly entered in the Reactor Operators' log book, the computer data had not been erased, and engineering personnel had reviewed the computer data. The absence of any recommendations leads me to conclude that the DPV Panel accepted any level of inspection effort, even if inadequate, to " disprove" my concern.
Next, the DPV Panel proceeded to discredit me professionally. The Discussion contains the following statement:
He did not review pertinent background material (resident reports or panel documents) or discuss the issue with the residents before-accompanying 01 to the site.
This statement and others collectively imply that the necessary information was available and that I was responsible for performing such a review.
Further, the Discussion implies that I was at fault for not knowing about matters (such as that an enforcement panel had been conducted) that management elected not to inform me of.
I commonly conduct a comprehensive review of background information when preparing for inspection; however, as I told the DPV Panel, management indicated that my involvement in the issues was intended to be insignificant.
I was directed that my role would be to simply keep the 01 investigator from becoming " overwhelmed" by technical information and commonly used acronyms.
In fact, when I rpecifically asked what I was supposed to do, Mr. Gibson directed me to " Keep your mouth shut and speak only when you're spoken to."
This reinforced my understanding that my management desired my presence to be supportive rather than participatory, and clearly not to conduct any inspection. When I did attempt to inspect this event more completely, Mr. Gihson told me he did not want me doing any further inspection because of the on-going 01 investigation. As inspections by other personnel continued, management took no actions to inform me of activities or results. The extent to which I was able to stay informed was through my own initiatives and was beyond my expected role as Mr. Gibson clearly communicated te me.
Even though I explained this information to the DPV Panel. and informed them of Mr. Gibson's directive, they evidently decided to slant the findings to evade the issue and protect a senior manager.
Lesson ?: Refrain From Makina Inappropriate Comparisons Again, the DPV Panel evades the issue of concern, which was the loss of technical credibility wh M result! hom extreme and inappropriate s comparisons. The Chernoby comt* 1 ns have in fact been recognized by NRC management as inappropriate and r(c< mate, and were therefore discontinued (e.g., deletion of such a referetse wom the proposed Enforcement Conference remarks). Yet when 1 questioned such comparisons, management defended them as appropriate.
S. Ebneter 3 The fact that Crystal River's engineering staff was " bothered" at all indicates that the comparison was both technically and professionally inappropriate. Furthermore, Crystal River managers took exception to this comparison; specifically Mr. Bruce Hickle and Mr. Greg Halnon. I have included pertinent portions of these individuals transcripts where the Chernobyl comparison was discussed as Attachment 1 Whether Crystal River personnel "were probably as much bothered by FPC management's continuing comparisons to Chernobyl as they were of NRC's", and whether the 'NRC staff interviewed by the NRC Panel understood" the analogy, are irrelevant to whether licensee personnel were bothered by the Chernobyl comparisons made by NRC management.
An NRC action resulting in a loss of credibility can have both tangible and intangible effects. Although "The Panel determined from the two investigators that the reference to Chernobyl did not impact their investigations", the comparisons had a tangible negative effect on my own investigation and inspection'. Further, the intangible effects of credibility loss are discounted and go unaddressed. -
Finally, the technical comparisons made in the Discussion in an attempt to justify the comparison fall short. The reactor and systems technologies used at Chernobyl were substantially different from that used at Crystal River. The September 4 and 5, 1994, evolutions did not affect core reactivity, safety systems were not bypassed, and Identiffed safety limits were not violated.
Also, the fact that INP0 considers this a serious event should have no bearing on how NRC conducts business, including use of proper comparisons.
Lesson 3: Don't surprise the licensee The DPV P'nel failed to address my points that 1) NRC failed to inform the licensee in a timely manner of the level of NRC concern, initially leading them to believe that the matter was not considered especially egregious, then surprising them later with the opposite response, and 2) both the initial message that the incident was not of serious regulatory concern, and the subsequent opposite message that the event was "like Chernobyl" influenced the actions taken by licensee management toward the operators. Instead of addressing the issues which I raised, the DPV Panel discusses at length about the unrelated issue (not raised by me) of whether it is appropriate to introduce a topic at a meeting about a different topic, and haw the licensee should respond in a hypothetical instance of that nature.
The Discussion acknowledges the fact that the licensee was surprised at the November 22, 1994, meeting by the level of NRC concern to which this matter had risen. This acknowledgement directly substantiates the first portion of my concern. Furthermore, keeping FPC informed may have prompted FPC to conduct a timely in-depth review of the September 5, 1994, evolution resulting in identification of the September 4,1994, evolution earlier. The failure to identify the September 4,1994, evolution resulted in severe disciplinary actions against the operators involved including termination.
S. Ebneter 4 My concern that strong NRC statements at the November 22, meeting influenced the disciplinary actions taken.by licentee management toward the operators is substantiated by the sequence of events on record. At the November 22, meeting, licensee management stated that they had not immediately taken the involved SR0s off shift. One was still on shift at the time, and as a result of direct statements at the November 22, meeting, was immediately removed from shift duties. There is no evidence this action was planned by licensee management prior to the November 22, meeting.
Lesson 4: Include all knowledaeable eersons in the enforcement orocess Once again, the DPV Panel presents information in a misleading manner and does not address my actual concern. As I have repeatedly explained, the essence of my concern was that I was excluded from discussions of the case prior to July
, 1995. This included exclusion from active participation in the development of the draft NOVs and any discussions on proposed enforcement. It was only through my own significant efforts that I managed to keep informed to any extent at 'all regarding fcetual developments outside the direct scope of the 01 investigation. Had I been allowed to contribute my knowledge of the case and my general expertise, I believe that events would have proceeded more effectively and, productively. The DPV Panel attempts to refute my concern by documenting my involvement in the enforcement process subsequent to July 1995.
This was never in dispute and is completely irrelevant.
However, indirectly the DPV Panel acknowledges the validity of my concern. As stated in the Discussion, "The panel determined that Mr. Rapp was not included in the task of initially drafting the proposed violations in the July 1995 time period." However, the claim is then made that "This task is the administrative portion of the enforcement process," implying that the activities from which I was excluded were of no importance. This is not true and highly misleading. Obviously, the enforcement process is more than an administrative one, as an important decision making process occurs prior to the prepaeation of the supporting documentation. I was excluded from this import, ant part of the process. Further, the Discussion states that, "He was involved in the review of the NOVs." I did review and comment on the draft NOVs as documented in my memorandum to Ellis Merschoff dated July 27, 1995; however, my involvement was a result of my own initiative. Management did not seek this review, despite my obvious knowledge of the case. As I have repeatedly expressed, my continued efforts to participate had been directly rejected by management. The fact that Mr. Herschoff issued a memorandum dated August 9,1995, to advise me that he considered my knowledge of the case important does not change the fact that prior to July 1995, my participation was actively discouraged.
To illustrate how my participation prior to July 1995, was act.ively discouraged by management, the first time I was asked about my views on Crystal River was during an inspection debriefing with Mr. Gibson on July 11, 1995, about the missed criticality at H. B. Robinson. At this meeting, Mr. Gibson asked me to explain my differing view on the draft NOVs for Crystal River. I had been attempting for some time to get management to listen to my views and give them consideration so I explained to Mr. Gibson that although'l did not believe that the operators should have conducted an
S. Ebneter 5 unauthorized test, neither did I believe that they had committed the violations as stated in the draft NOVs. I did not believe that citing these violations would not be valid because the operators had used approved procedures, anticipated system response, and took compensatory measures. In response, Mr. Gibson falsely accused me of thekim that the operators had done nothing wrong, and basically told me T -
dng was in error. Mr.
Gibson went on to misconstrue what I had P - '
d to behave as if expressing my professional opinion was ine,'a. 9. He stated that the
. agen'cy needed to send a message that conduct < i. Ts is unacceptable, and ".
. . we need everyone to get behind this." E m though I have never contended that conducting unauthorized tests is acceptable, a comment in my FY 1995 performance appraisal stated that I feel inappropriate actions are justified if they result in a safety benefit. This accusation about me was untrue and had a chilling effect. As I told the members of the DPV Panel, I have never expressed this view, only that the operators had perform the evolution .
nominally within the bounds of plant operating procedures, which had aircady received a 50.59 evaluation, and that the balance of safety consequences versus safety benefit should be considered when developing any enforcement actions. -
The claim in the Discussion that my review of the 01 transcripted interviews
. . . was a related and important task." has been disproven. Recently, Mr.
Gibson has made derogatory remarks about the " matrix" I developed from the review of the OI transcripts saying that ". . . we have lost control of the Crystal River allegations" and the matrix ". . . is a mixed bag" and ". . . I have no faith the matrix captured everything." As directed by Mr. Gibson's memorandum to me dated August 31, 1995, the purpose of my review was to develop areas for future inspections; not to develop an index of allegations.
This is substantiated by the decision to exclude allegations of NRC wrongdoing from the review.
Lesson 5: Don't sinole out an individual The DPy Panel acknowledges the basis for my concern, stating "It is possible that the licensee did review the individual's performance more closely because of the NRC management comments," and "It is likely that NRC's comments were made with the intent that the licensee review the shift supervisor's actions more closely because of this past performance." In fact, during my discussions with the DPV Panel, Mr. Crlenjak said he took " great exception" to my contention that Mr. Fields was singled out by NRC management.
Yet the Discussion then denied the validity of the concern by stating "An individual was not singled out; predecisional enforcement conferences were scheduled with six individuals." This is a grossly misleading statement because the number of people brought in for enforcement conferences is irrelevant to the issue of explicitly encouraging extra licens'ee management scrutiny of a particular individual.
The Discussion contained the telling caveat that "It is appropriate for NRC managers to carefully raise concerns relative to a licensed operator's current performante based on previous concerns with the individual, providing the facts relative'to previous performance are known and pertinent." This
i e
- 5. Ebneter 6 statement serves only to further substantiate my concern. Mr. Fields was i singled out by Mr. Gibson in a conversation with FPC management about ". . .
certification / validation errors" by Mr. Fields. This established Mr. Fields as a regulatory liability to FPC. However, it is debatable whether the facts j of the previous performance were "known and pertinent." I discussed the validity of the finding with the Senior Resideri+, Inspector, Ross Butcher, who i told me that the regional inspectors work ". . . in a vacuum" and that the i inspector should have first discussed the issue with him before pursuing as a violation.
The statement in the Discussion that "Whether the licensee scrutinized the shift supervisor's actions more closely because of NRC management concerns was not revealed in the transcripts reviewed" is factually incorrect. As stated by Mr. Gary Boldt in his transcribed 01 interview. FPC did indeed examine the actions of Mr. Fields more closely because cf Mr. Gibson's contact. The relevant pages from Mr. Boldt's interview are included as Attachment 2.
As i told'the DPV Panel, if the NRC has a problem with the conduct of a licensed operator, we should take individual enforcement action rather than pressuring the licensee to do our dirty work. Otherwise, we should cite the licensee and leave it to them to handle internal personnel issues as they see fit. If Mr. Fields' actions were sufficiently egregious for Mr. Gibson to take the issue to FDC management, why did we not follow the established enforcement process and allow Mr. Fields to the opportunity to explain his actions directly to NRC management? -
Conclusion Since the management-initiated DPV Panel failed to fully examine my
" concerns," I can only conclude either they failed to understand what they were reading or they failed to seriously review the concerns I raised, in any case, the DPV process was a sham serving no purpose except to protect NRC senior managers. Furthermore, instead of my efforts being appreciated, I have been sul ected to both professional and personal ridicule, given work
, assign' merits that cannot be accomplished in the time allowed, isolated from the inspection process, and subjected to adverse and untrue statements in my performance appraisal for expressing my professional objections on safety issues. I doubt seriously if my professional contribution will ever be positively recognized by Region 11 management.
Attachments:
- 1. Portion of 01 Interviews with Mr. Bruce Hickle and Mr. Greg Halnon
- 2. Portion of 01 Interview with Mr. Gary Boldt
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22 MR. DOCKERY: --
looks for that.
23 Mr. Ilickle, we have heard, and this is totally 24 unrelated to what we've been discussing, but as a filler 25 here, we have heard from many people _or many instances t
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75 1 wherein the evolutions of the 5th and as it turns out the 2 4th were likened to Chernobyl. Have you heard that that 3 comparison?
4 THE WITNESS: Yes.
5 MR. DOCKERY: Do you know where that emanated 6 from?
7- THE WITNESS: As I understand that -- that was a.
. 8 statement that was made -- made by someone very, very high 9 in the Nuclear Regulatory Commission organization, 10 possibly by one of the commissioners. B'ut I don't know 11 that because I heard this information secondhand.
12 MR. DOCKERY: To your knowledge was that -- was 13 Chernobyl first uttered by -- by somebody in FPC or by 14 somebody in the NRC?
15 THE WITNESS: Well, I would say the NRC, but I 16 don't know what utterings'-- I mean, all together I don't 17 know what people utter all the time.
'18 MR. DOCKERY: Well, I understand --
19 THE WITNESS: I'wouldn't characterize it in any 20 way, shape or form like Chernobyl.
21 MR. DOCKERY: Well, I think we all have a little 22 -- we might have a little: bit of trouble with that 23 analogy. .
24 THE WITNESS: Okay.
25 MR. DOCKERY: But it has been termed it was
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l-l j 76 1 bandied about with respect to the evolutions on those two 2 dates and it's -- we just wondered if you knew the genesis 3 of it?
4 THE WITNESS: No. I --
I don't know the genesis 5 of that. I don't agree with that analogy, G
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,. :9, MR.--VORSE: Did-that'come down from NRC to you?
10- THE WITNESS: I Actually, that caine from all- over.
' I mean, there was people -- When you hear unauthorized l 12--' test, the-first thing you think of is Chernobyl. So -- l
' 13' MR. DOCKERY: Would that be the first" thing that
- 14'.you would think of?
15 THE WITNESS: I didn't think of that. I think-16' Paul Fleming hit me with that first. thing. 'But-we didn't
. 17-.-look at thht as being as-significant as Chernobyl.from a e
18 technical standpoint. Maybe a standard standpoint where
'19 4you had a violation of procedures, which there was -
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10 regarding'Mr.' Fields =. .Did you have any ' reason to question 11- his competence or his judgment or ability prior =to- !
12 September 1994?-
13 THE WITNESS: Not -- No. I wouldn't say his f
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' 19 that whether-he communicated well or not. I think, you 20 know, there's.always-been kind of a feeling that he's more 21 confrontational, maybe, than some others and may not
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- 23 'MR. DOCKERY: Mr. Boldt, would you characterize 24 the issue of Curve-8 --
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54 1 been a few other issues that have turned up with Dave.
2 And I don't recall whether they were before or after. But 3 certainly the 1991 reactor trips were.
4 But I remember getting a call from Al Gibson from 5 Region II regarding Dave's signing off on work requests, 6 some post-maintenance tests as being completed which were
.7 not yet performed. We probed that issue. It wasn't an
, . 8 issue of -- you know, of trying to intentionally falsify a 9 document. There's been some -- There's been a practice in 10 some cases where we're coming up out of' refueling outage 11 and there's a regularly scheduled surveillance that's 12 going to perform the post-maintenance test.
13 There have been cares where the work request h'as 14 been closed out because it's a scheduled evolution, and 15 then tnat test is subsequently performed and married with 16 the package.
17 But that was the isrua when we looked at it.
'18 Now, that was not a good practice, as a rule, not a good 19 standard There was no reason to have to close out the 20 work orders. So that issue had come up regarding Dave's 21 judgment and it was kind of in the back of our minds.
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- 15. the October-November 1991 reactor-trips, this particular.
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