Facility Logs and Records

Content

• Introduction
• Notice Summary
• Applicability
• Issue Summary
• Issue Significance
• Corrective Actions and Follow-up
• References

Introduction

This notice is one in a series of publications issued by the Office of Nuclear and Facility Safety to share nuclear safety information throughout the Department of Energy complex. For more information, contact Dick Trevillian, Office of Operating Experience Analysis and Feedback, Office of Nuclear and Facility Safety, U.S. Department of Energy, Washington, DC 20585, telephone (301) 903-3074. No specific action or responses are required solely as a result of this notice.

Safety Notices are distributed to U.S. Department of Energy Program Offices, Field Offices, and contractors who have responsibility for the operation and maintenance of nuclear and related facilities, and to other organizations involved in nuclear safety. Written requests to be added to or deleted from the distribution of Safety Notices should be sent to: BR Richard L. Trevillian, EH-33, Room E-460 GTN, U.S. Department of Energy, Washington, DC 20585.

The ESH Office of Information Management maintains a file of Safety Notices and supporting information. Copies can be obtained by contacting the Office of Information Management at (301) 903-0449 or by writing to the Office of Information Management, U.S. Department of Energy, EH-72/Suite 100, CXXI/3, Washington, DC 20585.

Notice Summary

This notice provides lessons learned in the area of facility logs and records. It summarizes situations in which required logs were either falsified, incorrectly entered or not completed at DOE facilities. Readers are reminded that such conditions are not consistent with DOE requirements and guidelines. ^1,2,9,10 Additional related commercial nuclear power experience is presented from Nuclear Regulatory Commission (NRC) Information Notice (IN) 92-30, "Falsification of Plant Records."⁴ DOE and commercial industry experience emphasize the potential adverse impact of improper logkeeping on nuclear safety, as well as representing possible violations of Federal regulatory requirements and criminal statutes. This notice also contains generic information regarding management controls which may be beneficial in ensuring accurate logkeeping consistent with safe and reliable facility operation.

Applicability

This notice is applicable to all U.S. Department of Energy (DOE) nuclear facilities that employ logkeeping in their safety-related activities. The Office of Nuclear and Facility Safety (NFS) encourages managers and supervisors to evaluate the need to reemphasize the importance of accurate and timely logkeeping. Although recommendations are provided for improving the accuracy of operator logs and records, no specific actions or responses are required as a result of this Safety Notice.

Issue Summary

Ongoing NS reviews of Occurrence Reports have identified instances of falsified, missed, or inaccurate log entries at DOE facilities.^5,6,7,8

In December 1991, while reviewing operator data sheets, a day-shift supervisor identified a discrepancy in the data related to a leak detection pit (LDP). The LDP had been pumped during the day shift, but manually recorded data taken to the next day's graveyard shift was not consistent with pumping the LDP. Instead, the recorded data was identical to the data taken on the previous graveyard shift. Subsequent investigation identified other discrepancies in the data sheets for the same shift, and determined that an operator had copied the previous day's data.

NS reviewers identified a number of instances of falsification of logs by fire watches and patrols. The most recent occurred in June 1992, when a Fire Patrol Supervisor observed a Fire Patrol Inspector in an office during a period when the Inspector would normally have been making rounds. When the Inspector left the office, a review of his logsheets by the Supervisor revealed that the Inspector had falsified log entries for inspection of a number of areas. In November 1991 and March 1992, personnel at the same facility investigated similar events involving falsification of logs by fire patrols.

Previous to these events, in June 1991, personnel at another DOE facility reported another occurrence involving falsification of logs by a fire patrol. Fire watch activities were required every 2 hours on backshifts, weekends, and holidays while a fire alarm/detection system was out of service for modifications. An operator assigned to perform these duties made a routine inspection at 1600 hours, and then completed the log sheet for the entire swing shift, including false entries for the 1800, 2000, and 2200 hours.

In February 1992, an HP inspector at a DOE facility was discovered to have a Radiation Worker Training (RWT) qualification card with a falsified instructor's signature. The inspector had failed an examination at the conclusion of RWT, but was able to obtain a blank qualification card and falsify the instructor's signature. The Health Protection Division reviewed all applicable records and found no other falsified RWT qualification cards.

As described in IN 92-30, similar events have recently been identified in the commercial nuclear power industry.

In March 1992, the shift superintendent for the Public Service Company of New Hampshire's Seabrook Nuclear Station was conducting a surveillance, in accordance with a personnel performance monitoring program, to verify that operations department personnel were properly performing their assigned duties. On this occasion, the shift superintendent reviewed the security department's computerized card key entry records against locations in which as auxiliary operator's (AO's) log entries had indicated that he had performed inspections. The shift superintendent found that the AO had logged "SAT" (satisfactory) for some plant areas, indicating that he had performed the required periodic inspections, although the computerized security data indicated that some of these areas had not been entered.

The shift superintendent's findings prompted the licensee to establish an independent review team (IRT) to perform a comprehensive analysis of the root cause(s) and the generic implications of this occurrence. The IRT interviewed the individuals involved and the management and supervisory staff. The IRT also examined a wide range of historical records created or used since the full power operating license was issued, including security logs, operations logs and procedures, administrative program manuals, and training lesson plans. Some of the deficiencies found by the IRT involved licensed operators and violations of technical specifications.

In response to the finding at Seabrook, the Northeast Nuclear Energy Company (NNEC) conducted random checks at its Millstone Nuclear Power Station. NNEC determined that several non-licensed plant equipment operators (PEOs) had not completed certain inspection rounds as represented in their logs. NNEC has since expanded its evaluation to verify the accuracy of log entries recorded by all PEOs. Falsification of records has also been recently identified at a number of other commercial nuclear power plants, including Oyster Creek, Callaway, and Indian Point. ^4,11

As a result of discrepancies found at Seabrook, Oyster Creek, and Millstone, at least one individual had his employment terminated, several individuals resigned, and several other individuals were suspended. Various levels of disciplinary actions were also taken at DOE facilities where records were falsified. In addition, the NRC has issued a Temporary Instruction to the NRC Inspection Manual, requiring that Resident Inspectors evaluate the potential for falsification of records at all commercial nuclear power plants.¹²

Issue Significance

Accurate and timely logkeeping enables operations personnel to be cognizant of system and equipment status and trending information. As stated in DOE Order 5480.19, "Conduct of Operations Requirements for DOE Facilities," Chapter 2, "The recording of key equipment parameters during tours provides a record of equipment performance and can be used to reconstruct events leading up to unusual occurrences of system malfunctions. This record permits short-term trending by operators so that undesirable trends and equipment problems can be identified and corrected." As indicated in the NRC Information Notice, the protection of public health and safety "is provided in large part by the integrity and conscientiousness of each individual performing these activities." Personnel must understand the importance of obtaining and recording accurate information on a timely basis even when the parameters or equipment status appear to be static.

In part, logkeeping and data recording provide the eyes and ears of control room supervision and facility management. Negligence in this area can result in a decreased level of protection afforded to the public and workers, unnecessary damage to equipment, the occurrence of significant events, and a reduced ability to respond effectively to these events. For example, in one of the events described previously, a fire watch falsified records documenting inspection of specific areas while a fire alarm/detection system was out of service. Should a fire have started and gone undetected while the system was out of service, the sprinkler system may not have extinguished the fire. Complacency by personnel who have logkeeping responsibility erodes and compromises management's ability to assure safe and reliable operation of their facilities.

Correspondingly, the accurate documentation of surveillance test results and prompt notification to management of failed tests are also essential to nuclear safety. Surveillance tests are designed to support OSRs and to ensure the operability of systems and essential safety equipment. The failure to accurately document results, or to take action in response to failed tests, can contribute to a significant reduction in facility safety and the ability to mitigate the consequences of an event or accident.

Corrective Actions and Follow-up

NS review of the most recent information on this issue indicated that systematic reviews of record keeping practices at commercial nuclear power plants are being conducted by commercial utilities and the NRC. Some guidance on the methodology for this type of evaluation can be found in the NRC Inspection Manual, Temporary Instruction 2515/115. Because of the extreme importance of accurate log keeping to safe operation, NS recommends that similar, systematic reviews of record keeping practices also be performed at DOE facilities.

In addition, NS encourages managers and supervisors to consider other measures to enhance the accuracy and validity of logs and records associated with nuclear safety. For example, management should consider disseminating this information along with any related facility specific problems or events to all personnel responsible for logkeeping or data gathering. Additional actions that may be considered include:

• conducting retraining and/or meetings to reinforce the importance of obtaining and recording accurate readings, and emphasizing the associated safety benefits from this activity.

• requiring managers or supervisors to periodically accompany operators or technicians on routine rounds while observing that:

  • parameters are accurately read and recorded,
  • instrument scales are correctly interpreted and conversion factors are consistently used,
  • readings are taken from instruments that are operable and calibrated,
  • the operator or technician understands the importance of a particular reading including its relevance to equipment or system performance or safety significance as specified in applicable OSRs,
  • any out-of-specification, OSR-related reading is appropriately highlighted and immediately reported,
  • there is sensitivity inspecting operation equipment and initiating corrective action for deficient conditions.

• ensuring that operator logs and surveillance test data sheets provide any OSR-required limits or ranges.

• conducting periodic, independent verifications of required readings which typically do not change from shift to shift.

• ensuring continuous operator accessibility to instrumentation by providing:

  • permanently installed access ladders or scaffolding or remote indicators,
  • equipment labeling to avoid confusion,
  • adequate lighting,
  • control of contamination in accordance with ALARA principles.

• requiring managers and supervisors to periodically monitor surveillance tests with particulate attention to:

  • data sheets being at the test location,
  • data being recorded on a real time basis rather than recording data by memory at a different time and location.

• eliminating unnecessary readings which do no ensure equipment operability or nuclear and personnel safety.

• ensuring that administrative procedures require highlighting out-of-specification OSR readings (red circle, underline, etc.) and require immediate notification to supervision of such conditions.

• stressing the importance of accurate logs and records during relevant areas of training including site orientation or general employee training, operator, maintenance, radiological protection and related refresher training courses.

• wherever possible, ensuring that the scales used to obtain readings utilize the same units which appear on the logs. This human factor issue can assist in preventing errors caused by inconsistent interpretation and conversion.

• evaluating other applicable human factors improvements to facilitate logkeeping activities.

References

1. DOE Order 5480.19, Conduct of Operations for DOE Facilities, July 9, 1990

2. U.S. Department of Energy Safety Guide, Office of Nuclear and Facility Safety Policy and Standards, SG830.310, Guidelines for the Conduct of Operations at DOE Facilities, July 1991

3. U.S. DOE Environmental, Safety, and Health Performance Objectives and Criteria for Technical Safety Appraisals at Department of Energy Facilities and Sites, June 1990

4. NRC Information Notice 92-30: Falsification of Plant Records; April 23, 1992

5. ORPS Report RL--WHC-WHC300EM-1991-1008

6. ORPS Report RL--WHC-TANKFARM-1991-1082

7. ORPS Report SR--WSRC-HPIH-1992-0001

8. ORPS Report SR--WSRC-REACK-1991-0004, 0049, 0147

9. 18 U.S.C. Chapter 31, Records and Reports, 2071 "Concealment, removal or mutilation generally"

10. 44 U.S.C.Chapter 31, Records Management by Federal Agencies, 3106 "Unlawful removal, destruction of records"

11. NRC Event Numbers 23947, 24000

12. NRC Inspection Manual, Temporary Instruction 2515/115, "Verification of Plant Records"