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Shortly before midnight on July 1, 1985, Fermi 2 was in the process of start-up (Kline 1-8). Kline, the reactor operator, had expected the reactor to go critical at step 156 (Kline 6 and 7).
At step 56 he realized that he had made an out-of-sequence rod pull (Kline 13–14). At about the same time that Kline had noted indications of errors. Dewes, the Shift Technical Advisor in Training who had been observing Kline, told Kline, "Bill, I think you are critical." (Dewes 5 and 8). The out-of-sequence pull involved pulling 11 group three rods from 00 to 48 instead of from 00 to 04 (Aniol 14 and Myers 27) (Exhibit 13). As soon as Kline became aware of the out-of-sequence rod pull, he started to put the rods back in (Kline 14).
Kline instructed Dewes to notify Aniol, the Shift Supervisor (Kline 14). Dewes notified Aniol (Dewes 13-14). Aniol instructed Kline to re-insert all of the group three misaligned rods back to their initial position and then start over (Aniol 14). Aniol was apparently calm and not in an excited state during this incident.
Kline did not make an entry in the control room log. It is the responsibility of the Nuclear Supervisory Operator to do that (Kline 23). The entry was not made apparently because Burt, the NSO, did not know of the event until his next shift (Burt 7). But Kline said the mistake is shown in the rod pull sheet, "you can see where the rod was right here. It was 1851 [sic] when I realized I made a mistake---it was all there in black and white (Kline 51–53). [The pull sheet which is not part of the Exhibits shows that an error had been made. The pull sheet appears to be a quality record that is required to be maintained. }
Kline stated repeatedly that the facility had not gone critical (Kline 17, 18 and 27).
Corrections to Reactor Engineer's Log
Myers, the Reactor Engineer, was told by Dewes of the rod pull error (Myers 8). He originally recorded in his log:
Citations have been made to the page where the witness' statement is made in the exhibit. "A" following a page refers to a page in an "A" exhibit.
"The operator at the panel pulled the Group III rods to
He later amended his log by lining out portions of the the original entry and amending it to read:
"The operator at the panel pulled the Group III rods to
Myers made his original entry in his log book relying on the statement of Dewes that the plant had gone critical (Myers 8 and 27). After looking at the log, Aniol told Myers that the plant had not gone critical (Myers 9). Myers agreed to amend the log based on Aniol statements and clarifications from Dewes (id). Myers states that he made up his mind to clarify his log before talking to the shift supervisor. Myers said it is not true that Aniol directed the changes (id). He based the changes on information from Dewes (Myers 12-13). However, he also responded "that is true" to the question that the sole basis for changing the log was what the shift supervisor told him (Myers 21). But Arora, Myers' supervisor, said he interviewed Myers on July 2, 1985 and asked him why he made the change. Myers said he wanted to convey the information Dewes wanted him to convey (Arora 5). Myers had not done an evaluation of the criticality (Arora 6) (Myers 9, 12). [The reactor engineer's log appears to be a quality record that is required to be
Deviation Event Report (DER)
Aniol called Preston, Operations Supervisor, at home about 12:30 a.m. on July 2, 1985 (Preston 8) and informed him there had been an operator error in that a number of rods had been withdrawn past their withdrawal limit that was specified on the rod pull sheet (Preston 9). Preston was informed that the reactor did not go critical (id).
Preston reminded Aniol that a DER should be prepared (Preston 9). Preston wanted to have a DER on record even though it appeared to be an administrative matter (id). Preston noted to Ol that it
was his impression that even if not asked Aniol would have prepared a DER (Aniol 11). Lessor, Nuclear Consultant, said Aniol would probably have initiated the DER without Preston's instructions (Lessor 12). Flint, Assistant Shift Supervisor, stated at the time Aniol called Preston the DER was half written (Flint 11).
Preston stated that there was no procedural requirement specifying that an out of sequence withdrawal error be documented on a DER or any other document other than the pull sheet (Preston 12). The error was not documented on either the Reactor Operator's or Shift Supervisor's logs. 2/ It was documented on the pull sheet (Kline 53). There was no dispute that it should have been in the logs (Overbeck 29A). In contrast to the Shift Supervisor log, which is read by only Preston and, according to Preston, maybe the NRC inspectors, a DER is the most widely published paper made as it is viewed by every level of management (Preston 16 and 17). Overbeck, Assistant Plant Superintendent, stated a "cover-up" is inconsistent with writing a DER since by writing a DER it was telling everybody that there was an out-of-sequence rod pull (Overbeck 27A and 29A) (Preston 26A). Lessor stated if they were going to cover up, you would not prepare a DER (Lessor 18A).
A DER was prepared and it stated that the reactor did not go critical (Exhibit 13).
A. July 2 Morning Turnover Meeting
During the turnover process on July 2, Preston discussed the DER with Aniol. Lenart, Assistant Manager, was present (Preston 3A). Preston told Lenart that the DER would be processed at the Corrective Action Review Board Meeting that afternoon and that the reactor had not gone critical (id). After Lenart left, Aniol mentioned
Preston also noted that the content of control room logs is somewhat subjective (Preston 12). He would have expected to have the matter logged (Preston 13). Overbeck had the same view (Overbeck 24A). There was a need to improve the quality of logs (Preston 43). Overbeck noted that there had been a number of problems with events not being properly logged and the absence of any control room logs is indicative of the history the plant had of very bad logs (Overbeck at 26A). Aniol complained to Preston that logs in the control room were not factual (Preston 21, 44). Aniol was referring to the correction of Myers' log (Preston 22 and 23). Lessor said in his investigation of the logging issue that Aniol noted his logs had been criticized and that he was afraid to log (Lessor 12).
the need to have more controls over various logs in the control room citing the revision of Myers' log (Preston 3A and 4A, see footnote 1). It was at that time, after Lenart left, that Preston learned that Myers had originally logged that the reactor went critical (Preston 5A). However, Preston was under the assumption that Myers' original entry was in error (Preston 6A). 3/
B. July 2. Afternoon Corrective Action Review Board Meeting (CARB)
In a morning meeting on July 2, 1985 Preston gave the DER to Overbeck (Overbeck 6). Overbeck's reaction was "shit, what happened?" (id). Preston said based on the DER the reactor was not critical (Overbeck 7). Overbeck said we will discuss it at the CARB that day. (id).
At the CARB meeting Overbeck stated that the DER was discussed including the positions of the operators that the plant did not go critical and the "feeling on my reactor engineering side" that possibly it had been critical (Overbeck 10 and 3A). However, Lessor said criticality was not discussed (Lessor 3A). Overbeck said he (personally) did not have, at that time, indications of criticality (Overbeck 12), but he knew there was a difference of opinion (Overbeck 3A). Overbeck directed that the event be independently evaluated by reactor engineering. He knew what the operators said. He wanted someone separate from the operators to do the evaluation. (Overbeck 10) He assigned a due date of July 9, 1985 because in his view it was a significant event and wanted a review in a week (Overbeck 11).
C. July 3 Morning Meeting
In the morning of July 3rd, prior to the larger meeting (Preston 4A), Preston met with Reactor Engineering people who informed him that the reactor had gone critical based on SRM charts. They had coupled the charts with actual rod withdrawal times and the notches drawn to (Preston 13A). It appeared to Preston the reactor was very definitely critical (Preston at 14A). IIowever, upon further questioning it was determined that the wrong section of the chart had been looked at (id). They were looking at approximately 16 hours before the incident (Preston 16A). The reactor engineer,
There is no indication that Preston was advised by Aniol that Myers had a "differing professional opinion" as suggested by the OI report. In fact Myers had not done an evaluation (Arora at 6) (Myers 59) and he was relying on Dewes' statement (Arora at 5). He acted as recorder. There is no statement by anyone that Myers had a "differing professional opinion."
Thorpe (Preston 16A), had misinterpreted the information entirely (Preston 15A). Preston brought this to Thorpe's attention and the need for him to re-evaluate, to do his home work again because he was off base (id). At this point in Preston's view the reactor engineering credibility in their ability to tell criticality "was almost nil" (Preston 16A). 4/ Lessor also stated that reactor engineering "had lost a little credibility" by pulling out the wrong chart (Lessor 21A).
July 3. Afternoon Meeting
At the July 3rd afternoon meeting the correct portion of the chart was used (Preston 17A). After reviewing the correct portion, the view of reactor engineering changed from critical to it could have been (Preston 17A). There were two camps, one saying critical on the basis of the computer model (Preston 25) and the other saying not critical on the basis of the charts (Preston 26 and 17A). Thorpe had a similar view of the division at the meeting (Thorpe 9). No one from Nuclear Engineering other than Thorpe 51 thought it was critical or expressed that opinion (Lenart 17A).
Thorpe argued at the meeting for criticality based on his knowledge of the core and worth of the rods (Thorpe 9). Thorpe thinks he was the only one convinced of criticality (Thorpe 10). He had been working with the rod pattern for a year, so he did not expect the other engineers to react the same way he did (Thorpe 29). Other people Thorpe said thought it might not be critical and it was too close to call. In retrospect he says they were correct. There was not enough data to say one way or the other (Thorpe 10). Thorpe does not believe the operations people disregarded his analysis. Thorpe said they look at criticality from a different perspective; they are trained to look for a certain response on the chart which "certainly was not there." (id and at 11). The operations people were not inexperienced in criticalities (Thorpe 11). Thorpe did not perceive himself as one against the world (Thorpe 19). The others had more experience in investigating problems. Rather than proceeding with a "pre-conviction of what the outcome" is going to be, they were Inore cautious (id). Thorpe said in retrospect the others had a "more correct position." (Thorpe 20). The record of
Thorpe was not questioned concerning the July 3, 1986 morning meeting
with Preston nor was Preston asked who were the "Reactor Engineering people."
The term "dissenting" was used by the OI investigator in questioning Preston (Preston at 17A) and Arora (Arora at 10). None of the witnesses described either Thorpe or Lessor as a dissenter.