Date: February 24, 2003

To: Report Recipients

From: The Potable Water Incident Investigation Team

Belle River Power Plant

Late last year, Detroit Edison management and Local 223 officials announced their intent to form a joint team to conduct an investigation of a 1989 incident involving hydrazine at the Belle River Power Plant. The investigation came as the result of concerns raised by employees that the 1989 incident may have resulted in associated health implications.

The investigation team established a charter and established a commitment to the current and previous employees and contractors at Belle River, to conduct a complete investigation. We are announcing with this letter that the investigation has been completed. We have poured over hundreds of facts, documents, drawings and procedures and feel we have done an accurate job of concluding, where we could, the events associated with the potable water contamination event of August 15, 1989.

The attached report is the culmination of the Team’s work. Please take the time to study its contents and understand that we based our conclusions on the facts. We would like to thank everyone for his or her input. Your cumulative observations helped us derive our conclusions.

We do appreciate those contributions.

Remember that this report will be transmitted to the National Institute for Occupational Safety and Health (NIOSH) for their review and use in the Health Hazard Evaluation (HHE) process.

Send written correspondence to:

PWIIT

4505 King Road

OR

1. Executive Summary

2. Table of Conclusions

3. Conclusions

A. Water Issues

B. Glossary

C. Team Charter

D. Cross Connection Diagram

This investigation began as an employee issue, with Union officials coming to Management in September

of 2002. These employees were concerned that several employee illnesses and an employee death

were possibly linked to some hydrazine contamination in the potable water system at the Belle River

Power Plant ("BRPP"), discovered in August of 1989. These employees felt that the issues had not been

properly investigated in 1989. Plant Management promptly formed a team, known as the Potable Water

Incident Investigation Team ("PWIIT" or the "Team") to investigate the duration and the extent of the

hydrazine exposure This Team was comprised of (about) equal numbers of represented and 

non-represented employees.

The Team retained an outside expert in Root Cause Analysis to assist with the investigation, and

developed a charter. The Charter gave the Team the direction and authority to do the following:

cross connection;

organizational improvement; 

and Health (NIOSH) for a Health Hazard Evaluation (HHE).

The Charter also provided the following protections to employees who provided the Team with

information:

A copy of this Charter is attached to this report in Appendix C.

This investigation focused on the facts surrounding the incident itself. There was a clear distinction made

early on to separate the incident investigation from the analysis of any health impacts that could be

associated with the exposure. That "health impact" was to be studied by a third party, capable of that

analysis. After careful consideration of a number of health professional resources, the Team decided on

and contacted NIOSH. This report was sent to them for their review. The Team is familiar with the

protocol that NIOSH established for performing Health Hazard Evaluations and expects that NIOSH will

perform a full review of any health impacts that could be associated with the hydrazine exposure.

The Team searched several sources for information. They used Document Control personnel at the plant

to locate operating records, work order records, etc. Employees at the plant (and other locations)

retrieved old reports and data sheets. The Team commissioned several engineering studies and

performed several observations. The following is a short list of statistics…

Members of the Team are from the plant and corporate offices. The average workplace experience of a

Team member is 25 years. Collectively, the Team didn’t possess the skills to work through an

investigation process like the one required in this case. We employed the services of an outside Root

Cause Analysis (RCA) firm recommended by the Nuclear Generation group. The firm, Conger & Elsea,

Inc. introduced us to various elements of an RCA process, guided us through the process and assisted us

in preparing this report. Their help in the case was immeasurable. We possessed the link to the employees 

and the knowledge of plant geography, and they possessed the tools.

The following is an overview of the Conclusions reached by the Team as a result of its investigation. It is

important to understand that the Team was able to draw its conclusions based only upon the factual

information it received. It was not able to draw conclusions based upon hearsay or undocumented

information. 

Time:

The cross connection was most likely in place at different times from the summer of 1984 to

about August 8, 1989. Although it is possible that hydrazine could have entered the potable

water system at earlier times as a result of improper valving of the cross connection, the Team

has found no specific information that supports releases prior to 8/8/89. It is noted by the Team,

however, that there is insufficient documentation to conclusively rule out prior releases of

hydrazine into the potable water system due to improper valving of the cross connection during

these times.

Magnitude:

various locations in the potable water system. (Sampling began just after the cross connection

was disconnected but roughly 24 hours after flushing was initiated on some points of the system

due to complaints about the quality of the water. The Team is aware of only two samples that

were collected prior to the flushing beginning). Other samples taken from the test group icemaker,

in the same time frame, showed actual levels of 0 to 17 ppb. Because of a lack of sampling data

and because of other factors such as dilution and the reaction of the hydrazine with the oxygen in

the potable water, the actual amounts of hydrazine at various times and locations during the

August 8, 1989 to August 15, 1989 time period cannot be determined. What can be determined,

however, is the fact that during this time period the levels of hydrazine in the potable water were

never above 238 ppb (the highest level of hydrazine in the HWHS during that time period). In

addition, in the event that there were releases prior to this August 1989 time period as a result of

improper valving, the levels of hydrazine that may have entered the potable water cannot be

determined.

Location:

The documented locations where hydrazine was found in the potable water system were the Unit

2 Power Block and the Commons areas. Seventy-five (75) samples of the potable water were

taken from 8/14/89 through 8/22/89. Of these samples, sixty-four (64) read 0 ppb. The other

eleven (11) samples indicated that hydrazine was found in the potable water system in the Unit 2

ground floor men’s hot water tap, in the water lab and in the instrument shop sink and fountain in

the Commons area. Hydrazine was also discovered in the ice in the test group icemaker and

In the near future, the Team will be recommending corrective actions to be implemented by the plant.

From the recommendations, several work activities will be identified. Some corrective actions may have

already been addressed as part of the original investigation or as part of the general maturing process for

a new organization and plant facility. All recommendations will be reviewed and approved by senior

leadership and implemented by current plant staff.

The Team is expecting to interface with the next phase, NIOSH’s Health Hazard Evaluation. The Team

will be in communication with the lead NIOSH investigator on a regular basis to clarify the Team’s role

and to answer questions or provide any additional information that NIOSH may need. More details as

they become available will be transmitted to all the workers involved.

The Team would like to acknowledge the leadership of the Union and Power Generation for their

commitment and willingness to support this effort. Without Mike Langford and Doug Gipson signing the

charter, empowering this Team to investigate this event, this report would not have been possible.

In addition, special mention should be made to the following people for their work in support of the

Team’s investigation activities:

1. Sue Bailey

2. Mike Bennett

3. Dr. David Hay Garabrant

4. Terry Hall

5. Georgia Hoyer

6. The "Interviewees"

7. Bob Nearhoof

8. Al Sears

9. Dave Sonntag

10. Art Zwierzchowski

11. Rita Lane

12. Bruce Kidder

13. Ken Elsea

Hydrazine was introduced to potable water system by improper operation of an

undocumented cross connection.

The unauthorized cross connection was most likely in place at different times from the

summer of 1984 until 8/15/89.

The first documented proof of hydrazine being in the potable water was on or about

August 8, 1989.

The amount of hydrazine in the potable water system between August 8, 1989 and

August 15, 1989 was less than 239 ppb.

The documented locations where hydrazine was found in the potable water system

were the Unit 2 Power Block and the Commons areas.

Hydrazine in the potable water system most likely did not enter the Administration

Building, Ash Unloading, Change House (pipe shop), Clubhouse, the Document Control

Building, Garage, Main Gatehouse, Warehouse ‘B’, Warehouse ‘C’ and ball diamond.

Hydrazine intrusion into the potable water system via the cross connection was stopped

on 8/15/89.

Discussion:

The physical link between the potable water system and the HWHS HVAC unit (00V9060), heating coil (OE9067),

was a hose. The hose connection to the potable water system was made to a temporary copper tubing hook up that

had been installed for a clothes washer. The hose connection to the HWHS was made to the heating coil drain.

Although plant policy required a work order to perform work (such as making a connection between systems), none

was found. Not only was the cross connection undocumented and unauthorized (done without a PN-21 and outside

of PPO 77), but the improper operation of the valves allowed an open pathway between the systems. This operating

practice was not in accordance with normal operating procedures (System Description Hot Water Heating System

M-0016). In addition, the documented operating pressure of the HWHS (160 psi) was greater than the potable water

system documented operating pressure (80-100 psi). Therefore, with the valves opened between the systems, water

(including hydrazine) from the hot water heating system entered the potable water system.

Supporting Facts:

1. Bechtel had Hydrazine on site initially in 1978 for the auxiliary boilers. (D-23)

2. HWHS operation for the Service Building is contained in Operating Procedure OP-1-0016-002 Hot Water

System. (D-2c)

3. Hydrazine was used in the Hot Water Heating System ("HWHS") beginning in 1983. (D-59, D-14d and D-54)

4. Potable water system operation is covered in Operating Procedure OP-0-0017-003 Pressure Booster System -Service

Building. (D-14a)

5. Potable water system design operating pressure is 60 psi on leg 1 (downstream of valve 009) & leg 2

(downstream of valve 006) and 120 psi on leg 3 (downstream of valve 005) (M0017, sheet 1) (D-6a, D-14a)

room, near the hot water heater, so that another employee could hook up copper tubing to the washer. After the

employee heard that the washers were there, he began to use them. During the strike, the Plant Superintendent

learned about the washer hookups and made the employees remove the washers. The (cross connect) hose was

later connected to the copper tubing where the washer used to be. (I 123) (O-10)

7. An employee said that there were washing machines in the warehouse in the Service Building HVAC room.

There were two pipes on the wall near the hot water tank for the washer hookup. (I 38) During an observation

on 11/6/02, this same employee viewed the HVAC room with the Team, pointed to the south wall at the east

end of the hot water tank and stated "that’s where I think the hose was connected." (O-14)

8. An employee said that washers were on the east end of the potable hot water tank up against the wall in the

Service Building HVAC room. This area now has more filters and pipes than it did back then. Stuff was added

when the plant began having problems with the copper pipes. (I 71a)

9. Normal HWHS operation valve line up, according to Operating Procedure OP-0-0058-001, Service Building

Heating, Ventilating, and Air Conditioning Systems ("HVAC") equals heating coil inlet and return open, and

HC drain and vent closed. (D-14c)

10. HWHS documented pressure was 160 psi after the 8/15/89 discovery. (BT-63, BT-66)

11. A hose was connected between a potable water line and an HVAC heating coil (0E-9067). (I 89, I 127, I 132

and I 140, BT-63)

12. An employee pointed out the areas where the hose was connected... The hose was run straight up and overhead

across pipes (to the north) above the HVAC (00V9060) HWHS heat exchanger (OE-9067) drain line outlet and

connected near the floor drain. A separate hose (dark and heavier than a garden hose, like a wash down hose, 

not a Tygon hose) was connected from the heat exchanger vent line outlet to the same drain opening. (I 127, I

127a)

13. Valve line up for the undocumented cross connection, which allows potable water to flow through the heating

coil according to O-12, was HWHS inlet and return to the coil closed, and the coil drain and vent valves open.

(D-14c, BT-63)

14. An employee said that the two employees who installed the cross connection did not use a PN-21. (I 31)

15. According to Power Plant Order ("PPO") 77, Protection Procedures, work orders are required to perform any

work at the plant. (D-38)

16. The team could find no work order regarding the installation of the cross connection

17. The Team could find no drawing made prior to August 15, 1989, which shows the installation of the cross

connection.

18. Potential of intrusion occurred when HWHS coil source is greater than the potable water system operating

pressure and the valves are not properly lined up. Valves are not properly lined up when, for example, A, D &

E are open, providing 135 pounds of HWHS pressure, or B, D and E are open, giving 121 pounds of HWHS

pressure. See Appendix "D". (O-12, D-2c and D-62)

19. Hydrazine was detected in the potable water system on 8/15/89. (BT-4) (I 90a)

20. Piping and Instrumentation Diagram ("P&ID") M-0016 sheet 3 shows the location (00V9060) of the connection

that was discovered on 8/15/89, as marked after the discovery of the cross connection. (D-43, I 91a)

21. A memo from the Plant Superintendent dated 8/15/89 informs the BRPP employees that an unauthorized cross

connection was found between the potable water system and a heating coil in the ventilating equipment for the

operators’ locker room. The Memo further informs the employees that apparently a leaking heating valve

permitted backflow of the treated water in the HWHS to the potable water system for the plant. (BT-4)

22. In 1989, the potable water system documented operating system pressure in the leg used for the cross

connection was 80-100 psi (BT-63, BT-66)

23. The team found a 1-inch diameter red hose approximately 75 inches long, lying in the expansion joint of the

HVAC unit. When this hose was placed in the drain the extending end lined up perfectly with the vent line of

the heating coil, complete with internal witness marks from a ¾ inch pipe thread. The vent line on the heating

coil is 54 inches from the floor with the remaining 21 inches of red hose sticking down into the floor drain. (O-12)

24. HWHS observed operating pressure at heating coil inlet is 135 pounds. (O-12)

25. During an observation on 1/27/03, members of the Team and another employee viewed the ½ inch cut and

capped hot and cold water copper lines. The lines are directly below the southeast corner of the Service

Building HVAC room and are connected to the 3-inch hot and cold main headers. This ½ inch line teed and

went to the sink, drinking fountain and coffee machine in the maintenance supervisor’s office. (O-16). 

Discussion:

Employees’ memories differed in details concerning the cross connection. While some reported seeing the hose for

only a year or so, the earliest that some remembered seeing the cross connection was in 1984. The strike in 1984

was used as a "memory marker" by some of those interviewed. Employees’ memories also differed regarding who

was responsible for setting up the cross connection. It appears that the installation of the cross connection occurred

in two phases. First, during the strike, certain employees installed copper tubing to hook up washing machines in

other employees connected the hose to the potable water via this copper tubing. Employees reported that the cross

connection was either disconnected or "valved out" according to seasonal heating/cooling needs. The only written

records concerning the cross connection which the Team could locate concerned the discovery and removal of the

cross connection in 1989.

Supporting Facts:

1. An employee stated that another employee told him that this employee set up the system that resulted in the

hydrazine leak. (I 72)

2. An employee stated that he had his people hook up the washers and dryers in the Service Building HVAC room

during the strike. He also said that they were removed days after the strike. (I 32)

14), (I 38), (I 71a), (I 83a) (I 127)

4. An employee says he remembers seeing green hoses during the strike for connection of the water to the washer

in the second floor Service Building HVAC room. He did not see the cross connection. He stated that washers

upstairs stayed until the strike was over. (I 42a)

5. After the employee heard that the washers were there, he began to use them. During the strike, the Plant

Superintendent learned about the washer hookups and made the employees remove the washers. The (cross

connect) hose was later connected to the copper tubing where the washer used to be. (I 123)

6. An employee stated that he heard that sometime after the washers were disconnected, a garden hose was

connected. (I 127a)

some field piping and PVC, not copper. He thinks this was the remnant of the washer and dryer hookups. He

thinks that if there were a hose there, he would have noticed it as a safety (tripping) hazard. He does not

remember tripping over a hose or ducking under a hose between mid 1984 and mid 1987. (I 125)

8. An employee said that during the strike of 1984, he was in the beer tent and a group of four (4) employees told

him that they were up in the HVAC room and hooked up a hose from the potable water to the heating coil for

cooling the locker room. This employee asked the four employees if they hooked one up for another locker

room, and they told him to hook it up himself. This employee also stated that he saw the hose during the strike

of 1984. It was a green garden hose with a hexagon shape. It was hung above the HVAC along the wall and

connected to the coils in the HVAC. A red garden hose was over by the hot water tank on the lower line. Later

after the green garden hose became corroded and started leaking, a piece of Tygon tubing was used for a short

while. (I 103a)

9. An employee said that the cross connection was installed in 1984 by two other employees. Each employee

would play with the valves often. The original hose was Tygon with hose clamps. (I 31)

10. An employee first said that he saw the hose hooked up in 1984 to the chiller/cooler. The employee said the

hose was always there and always connected. The garden hose was there all of the time. (I 85) He later said

that as far as the cross connection goes, he saw it but he never did anything with it. At first he really didn’t

know what it was. Eventually, after the incident, he knew what it was. He stated that all he knows is that he

saw the hose there. He didn’t trace it out. He thinks it was there for a couple of years. (I 85a). 

11. An employee said that the hose was put in during the strike of 1984 to cool the locker room. (I 19)

12. An employee heard that the cross connection was done in 1984 to cool the locker rooms during the strike. (I

106)

13. An employee heard that the cross connection was done during the strike to cool down the upstairs locker room.

(I 107)

14. An employee heard that the piping changes were made to cool the locker room during the 1984 strike. (I 115)

15. An employee said he thinks the cross connection was hooked up during the strike. (I 124)

16. An employee heard that "so and so" did the cross connection in 1984. (I 73)

17. An employee stated that he remembers when the hoses were installed. It was around 1984 or 1985 or 1986,

sometime in that area. They were located above the tool crib area, in the room where the HVAC was. They

were either two 50-foot hoses or two 100-foot hoses involved in the area. (I 142)

18. An employee heard of the cross connection and that the water in the urinals and toilets was warm in about 1986

or 1987. (I 112)

19. An employee said that he heard that between 1984 and 1989 people put cooling water through the coils. He

thinks that the HWHS and the potable water systems were crossed over 5 times between 1984 and 1989. He

never saw the cross connection. (I 37)

20. An employee said he did not remember the hose connected at contract time (June 1984). He is almost positive a

green hose was connected but he only saw it connected for one year. (I 3)

21. An employee said that the Tygon tubing from the vent to the floor drain was not there in 1984 and cannot

pinpoint how long it was there. He cannot recall the hose connection from potable water to the HWHS. (I 64)

22. Employee notes (made in 1989) state at page 4 that at 11:00 on August 24, 1989 that he found out that the tap to

the potable water was made by the Maintenance Foreman during the 1984 strike. No BFR (Back Flow

Restrictor) (D-22)

23. Employee notes (made in 1989) first say at page 2 that the hose has been in that area for at least 4 years and that

the hose was tied to a beam. The notes further indicate that this employee asked another employee on August

16, 1989 how long the connection had been made, and that employee responded that it could have been in since

1984. These notes later at page 6 say that the connection could have been made "at least four years" ago. (D-22)

24. An employee first said that he remembers seeing the hose in 1984 or 1985. He later stated that he saw the

garden hose connected to the HWHS bottom drain coil. The connection could have been made in 1985 or 1986,

but not during the strike. He leans more toward 1985 because there was too much activity during the strike in

1984 to do the connection without being seen. He further stated that it was a green garden hose that was valved

out in the winter, but the hose was left there. (I 83 and I 83a)

25. An employee said that, in 1985, he saw the garden hose lying on the floor connected to nothing. It was coiled up

in the corner. He saw the hose hooked up in late 1985 or early 1986. He saw it hooked up once in 1989 when it

was busted. It was hooked up to the HVAC drain but was not hooked up to the potable water. (I 38)

26. An employee stated that he heard the hose was in place in the summer of 1984. The hose was not disconnected;

it was just valved out. He remembers seeing it for a length of time. He can’t specifically remember what year it

was. He thinks it was a year that we had a record heat wave of 9 days in a row over 100 degrees, maybe the

summer of 1985 or 1986 or 1987. Then, after that, the connection was just left there. He remembers operators

talking about putting it back into service for the summertime after that. He knows it was there in 1988 and it

was there for more than one year. He thinks the cross-connection was valved in every summer from the hot

summer we had until 1989. He remembers seeing a one inch black wash down hose with a pipe fitting on one

end and coming off copper fitting at the other end. At the time, the connection would be to spigots for a

washing machine, which is what a garden hose accepts. One end had to be standard threads and the other

national threads, so there had to be some kind of transition fitting. He said it could have been a garden hose, but

he remembers seeing a black hose. (I 50a)

27. An employee said he saw a green garden hose was there in about 1986 or 1987. He remembers seeing it for two

years. The first year it was on the floor. The second year it was connected overhead. He remembers the locker

room was cooler at that time. (I 14)

28. An employee (I 32) said he noticed the cross connection was present at the time of the "no smoking order,"

Plant Order BRPP-1043, effective March 1, 1988. (D-68)

29. An employee said that in 1985, they used the operator’s locker room. He noticed that the locker room

temperature would fluctuate, warm and cold. In 1988, the locker room temperature fluctuations became erratic,

which caused him to look at the HVAC unit. He saw the hose was connected to the hot water coil. It was not

connected to anything else. He saw water running out into the drain. (I 93)

30. An employee said he saw a garden hose in the HVAC room connected to the HWHS coils. Then the hose was

moved to overhead and he didn’t see it connected at either end. He didn’t remember how long he had seen it

connected. He thinks that maybe it was for three years. (I 92)

31. An employee said that he knew about the cross connection for better than a year before discovery. He also said

that the hose was "well done" and "hidden nicely." He said that he didn’t believe that the hookup of the cross

connection made any difference in the temperature of the locker room. He said that he remembers it was

unhooked in the winter and valved out in the summer. He didn’t think the valves are manipulated much, if it

was a hot spell outside during the summer, most likely the cross-connection was valved in. (I 127)

32. An employee said that he remembers that the cross connection was done 6 or 8 months prior to discovery. (I 9)

33. An employee said that he doesn’t believe that cross connection was installed during the strike of 1984 because

he does not remember anything going on in the locker room. He cannot remember if it was hooked up any

more than the year it was discovered. He thinks it was hooked up in June or July of that year. He cannot say it

was anymore than one year. It may have been, but he doesn’t remember. He does not remember it being

summer after summer. He cannot remember what year it was installed, but when it was working, it was

working, and people knew about it. It was a hose connection, a garden hose, not elaborate. He did see it; he

remembers it was green. (I 71a)

34. An employee said that the potable water was hooked up in warm months and was disconnected in the cooler

months. (I 26)

35. An employee said that he made rounds in the HVAC room. He remembered seeing a hose running to the

heating coils only on a temporary basis. The locker room was cooler for a short period of time prior to the

discovery of the cross connection. (I 96)

36. An employee said that he heard about the cross connection a week or two prior to the discovery. (I 27)

37. The cross connection was in place when employees "hooked back up" at 4:00a.m. on 8/14/89 (BT-66, same as

D-28)

38. The cross connection was in place when the work order was written to "hard pipe service water to the HVAC

unit for the operator’s locker room" on 8/14/89 (BT-1)

39. The cross connection was in place when discovered on 8/15/89 by a lab employee. (I 89, BT-3)

40. Garden hose removed on 8/15/89 per work order number 239483 (BT-3)

41. Hydrazine was verified to be removed from potable water system in the morning of 8/16/89. (BT-11). 

Discussion:

Although it is possible that hydrazine could have entered the potable water system at earlier times as a result of

improper valving of the cross connection, the Team has found no specific information that supports releases prior to

8/8/89. It is noted by the Team, however, that there is insufficient documentation to conclusively rule out prior

releases of hydrazine into the potable water system due to improper valving of the cross connection.

Based upon the sampling data from the water lab, the first date that hydrazine is documented to be in the potable

water is August 8, 1989. (On August 22, 1989, a lab employee sampled some ice from the Test Group Freezer that

was two weeks old and which revealed 0 to 2ppb of hydrazine in the ice.)

Other than the sampling data, the only other statements or documents that could show that hydrazine was in the

potable water prior to 8/8/89 are the interview statements regarding the temperature and quality of the water. These

statements differ drastically, and it is therefore difficult to draw any conclusions from them.

Many employees mentioned that there was warm water and/or a bad taste and odor to the water around the time of

the August 15, 1989 discovery. These symptoms/observations are most likely associated with hydrazine being

present in the potable water during that time period. Many others, however, recall these types of water problems

occurring either at times when the cross connection was not in operation (based upon the interviews) or in locations

where the hydrazine could not reach (as discussed in Conclusion #6). For example:

connection was most likely not operating.

employees remember the water problems stopping in or after 1992, years after the cross connection was

disconnected

affected by the hydrazine.

There is support for the conclusion that the opportunity to detect small amounts of hydrazine in the potable water

may not have always existed. For example:

the HWHS. If hydrazine were present in the potable water, it would likely have been discovered when the

reagent was added to the blank. Some lab employees, however, admitted to using condensate instead of potable

water for the blank. At these times, it is therefore possible that hydrazine could have been present in the water

but was unable to be discovered.

sample.

water. It is therefore possible that low levels of hydrazine could have been present in a sample, leading water

lab personnel to believe that a color change was due to the reagent.

It is therefore possible that, at times when the cross connection was in place, a release resulting in hydrazine into the

potable water occurred that was not discovered by water lab personnel. Based upon the above information, the first

verifiable time hydrazine was released into the potable water was in August of 1989.

It is impossible for the Team to conclude any amount or duration of hydrazine into the potable water system before

August of 1989 due to the following reasons:

First, two things had to occur for the hydrazine to enter the potable water: 1) The cross connection (hose)

had to be in place and connected; and 2) there needed to be an improper valving of the cross connection.

No employees have come forward and said they installed or operated the system incorrectly or that they

found the cross connection improperly valved. One individual has come forward, however, and said that,

when he checked the valving in 1988, it was properly valved.

Second, there has been no information provided to the Team that the events that happened around August

15, 1989 ever happened previously. In other words, the time period of August 14 and 15 was unique as far

as employees’ concerns over the quality of the water. For example:

China Township, and East China Township recommended flushing.

Although some individuals said that they had been complaining about the temperature or quality of the

water prior to August of 1989, there is no information that any employees took water to the lab for

testing prior to this. In fact, a water lab employee stated that employees would routinely take water to

the lab for analysis but it was his recollection that it was usually water from home. He also said that

the lab would run samples on any water that was brought to them. The Team has uncovered no lab

results from any such sampling.

warm in the lab, it usually cooled down after running the tap. It didn’t cool down on August 15, 1989.

discovered the hydrazine in the potable water on August 15, 1989.

Supporting Facts:

1. Bechtel had Hydrazine on site initially in 1978 for the auxiliary boilers. (D-23)

2. DTE hydrazine usage in closed cooling water and hot water heating systems at BRPP started in 1983. (D-14d)

Documented discovery of the Hydrazine in the Potable Water

3. East China Township Water Dept. was contacted by a lab employee on 8/14/89 and informed that there was a

possible odor and taste problem with the plant’s drinking water. East China Township Water Dept. advised this

lab employee to flush the lines. (BT-12)

4. An employee stated that, around the time of the discovery of the hydrazine, he received a call from the control

room questioning why the cold water was 95 to 97 degrees and smelled funny. He and another employee spent

most of the day looking for the source of the warm water problem. He cannot remember if they found the cross

connection that day or the next. (I 132)

5. An employee said that he took a water sample to the lab on 8/15/89 that resulted in the discovery of the

hydrazine contamination. (I 15)

6. An employee stated that he remembers that prior to the 1989 discovery, another employee took water to the lab

only to find out that yet another employee had already done so. (I 24)

7. Another employee stated that he heard that yet a fourth employee took a water sample to the lab on 8/15/89. (I

123)

8. A lab employee stated that, on 8/15/89, hydrazine was discovered as a result of the lab trying to cool samples by

running cold water over them. (I 89) This same employee stated that two other lab employees told him that the

water in the lab was running warm, so he turned the water on and let it run. He further stated that after coming

back from lunch, he found the water was still running warm. (I 90) This employee stated that it was not

unusual for the lab water to run warm, but it was unusual for it not to cool off. (I 89). 

9. This same lab employee stated that he conducted some tests on the potable water. First he found that the

conductivity was lower and the pH was elevated. He therefore ran a silica and a hydrazine test. The potable

water tested positive for hydrazine. This lab employee immediately started looking for the source of the

hydrazine. (I 90)

10. Another employee stated that, as a result of the discovery in the lab, he was asked to look for a cross connection

to potable water. He further stated that he discovered the cross connection on 8/15/89. (I 123)

Operation of the cross connection

11. Valve lineup for the cross connection, which allows potable water to flow through the heating coil according to

O-12, was HWHS inlet and return to the coil closed and the coil drain and vent valves open. (D-14c, BT-63)

12. Potential for intrusion of hydrazine into the potable water system occurred when the HWHS coil source was

greater than the potable water system operating pressure and the valves were not properly lined up. Valves are

not properly lined up when, for example, A, D & E are open, providing 135 pounds of HWHS pressure, or B, D

and E are open, giving 121 pounds of HWHS pressure. (Appendix D, O-12, D-2c and D-62)

13. An employee said that he heard about the cross connection about a year prior to discovery. After he heard

about it, he checked the valves to make sure that they were lined up correctly, and they were. (I 127) This

means that the inlet valve and the return valves to and from the HVAC heat exchanger were closed and that the

heat exchanger drain and vent valves and the potable water connection valve were opened. (I 127a)

14. An employee’s notes written in August of 1989 indicate that on the Sunday night shift a hose broke at

approximately 1:00 a.m. (8/14/89). The pump was found on, it was shut off and the coils were isolated. That

same night at 4:00 a.m. (8/14/89) an employee called and said that water was in his office. The hose had

popped off this time. The system was again isolated. (BT-66)

15. One of the employees that discovered the cross connection on August 15, 1989 stated that he thinks that the

release of hydrazine into the potable water occurred when the employee(s) repaired the leak in the hose. He

thinks that they closed all of the valves when they fixed the leak and then opened all the valves up. (I 89)

Valving of the Cross Connection

16. An employee stated that the green garden hose that was valved out in the winter, but the hose was left there. He

didn’t think the valves are manipulated much, if it was a hot spell outside during the summer, most likely the

cross-connection was valved in. (I 83 and I 83a)

17. An employee stated that he thinks that the hose was put in place the year that we had a record heat wave of 9

days in a row over 100 degrees, maybe the summer of 1985 or 1986 or 1987. Then, after that, the connection

was just left there. He remembers operators talking about putting it back into service for the summertime after

that. He knows it was there in 1988 and it was there for more than one year. He thinks the cross-connection

was valved in every summer from the hot summer we had until 1989. (I 50a)

18. An employee said that he remembers the hose was unhooked in the winter and valved out in the summer. (I

127)

19. An employee said that the potable water was hooked up in warm months and was disconnected in the cooler

months. (I 26)

20. Another employee said that he believes the potable water was hooked up only in the summer months. (I 71a)

Interview statements regarding potable water temperature and quality

21. A summary of the statements of the 16 employees who noticed a problem with warm water in general is

contained in Appendix A.

22. A summary of the statements of the 35 employees who noticed nothing unusual about the water in any regard is

contained in Appendix A.

23. A summary of the statements of the 21 employees who noticed warm water in the toilets is contained in

Appendix A.

24. A summary of the statements of the 14 employees who noticed nothing unusual regarding the water in the

toilets contained in Appendix A.

25. A summary of the statements of the 34 employees who noticed warm water in the drinking fountains is

contained in Appendix A.

26. A summary of the statements of the 19 employees who noticed nothing unusual regarding the water in the

drinking fountains is contained in Appendix A.

27. A summary of the statements of the 15 employees who noticed warm water in the cold water taps and sinks is

contained in Appendix A.

28. A summary of the statements of the 3 employees who noticed nothing unusual regarding the water in the cold

water taps and sinks is contained in Appendix A.

29. A summary of the statements of the 6 employees who noticed hot water in the showers is contained in

Appendix A.

30. A summary of the statements of the 26 employees who noticed nothing unusual about the water in showers is

contained in Appendix A.

31. A summary of the statements of the 9 employees who noticed warm water in the urinals is contained in

Appendix A.

32. A summary of the statements of the 12 employees who remember bad tasting coffee is contained in Appendix

A.

33. A summary of the statements of the 10 employees who noticed no problem with the coffee is contained in

Appendix A.

34. A summary of the statements of the 32 employees who had recollection of a color, taste, odor, texture or look of

the water is contained Appendix A.

35. A summary of the statements of the 23 employees who have a recollection of the unusual water conditions in

certain specific locations in the plant is contained in Appendix A.

Sampling of potable water

36. Hydrazine was detected, by sampling and testing, in the potable water system on 8/15/89 after lunch. (BT-4, I-89,

BT-11)

37. An employee took three samples of the ice contained in the Test Group Ice Maker on 8/22/89 at 1000 hours.

The results of those three samples were 17ppb, 8ppb and 7ppb of Hydrazine. (I 90b and BT-51)

38. On 8/22/89 at 1045 hours, an employee took two samples of ice that were generated two weeks previously

[which would be Tuesday, 8/8/89]. The results of those two samples were 0-1ppb and 1-2 ppb of hydrazine. (I

90b and BT-51) Although (BT-51) does not specifically reference the date that the ice was made, the employee

that took the samples stated that the reference to "2 weeks" means that the ice was 2 weeks old as of August 22,

1989. (I 90b) (See also BT-65, page 5)

39. On 8/22/89 at 1045 hours, an employee took one sample of ice that was generated two weeks and three days

previously [which would be Saturday, 8/5/89]. The result of that sample was 0ppb of hydrazine. Although

(BT-51) does not specifically reference the date that the ice was made, the employee that took the samples

stated that the reference to "2 weeks and 3 days" means that the ice was 2 weeks and 3 days old as of August

22, 1989. (I 90b)

40. On 8/22/89 at 1045 hours, an employee took one sample of ice that was generated two weeks and six days

previously [which would be Tuesday 8/2/89]. The result of that sample was 0ppb of hydrazine. Although (BT-51)

does not specifically reference the date that the ice was made, the employee that took the samples stated that

the reference to "2 weeks and 6 days" means that the ice was 2 weeks and 6 days old as of August 22, 1989. (I

90b)

41. On 8/22/89 at 1045 hours, an employee took two samples of ice that were generated one month previously

[which would be 7/22/89]. The results of both of those samples were 0ppb. Although (BT-51) does not

specifically reference the date that the ice was made, the employee that took the samples stated that the

reference to "1 month" means that the ice was I month old as of August 22, 1989. (I 90b)

Water lab procedures and sampling issues

42. The water lab procedure (used to test for hydrazine in water) for the Klett Summerson colorimeter was in the

possession of the lab by 3/9/82 (D-29). In July 1983, water lab personnel purchased the Bausch & Lomb Spec

21 colorimeter to test for hydrazine in samples. (D-75) The water lab procedure for the Bausch & Lomb Spec

21 colorimeter is in the document dated 04/20/87 revision 1. (D-29)

43. Water lab personnel are currently using the Bausch & Lomb Spec 20 colorimeter to test for hydrazine in water

samples.

44. An employee said that you would set a blank with a standard. The Spec. 20 are solid state. This employee

further stated that he liked the old Spec 21 better than the Spec 20. Readings with the spec 21 were better than

the spec 20. Readings with the Spec 21 didn’t vary as much as the Spec 20. (I 76)

45. An employee who worked for a while in the water lab said that during 6-82 through 9-85 he recalls using city

water as a blank for testing hydrazine. (I 29)

46. An employee said that he heard that city water was used as a blank to test for hydrazine. (I 15).

47. An employee said that potable water was sometimes used as a blank for testing hydrazine, but a blank was not

always used. (I 62)

48. An employee said that the control (or blank) used for testing was city water. Since city water was used, one

would have been able to detect hydrazine in the water prior to the 1989 incident if it was present. (I 97)

49. An employee said that prior to 1989, condensate water was used most of the time for the blank to test hydrazine.

There were a number of people in the lab and some used potable water. Other plants would use potable water

because there were traces of hydrazine in the condensate. He said that the sample would turn color when the

reagent was added if there was hydrazine present. (I 90)

50. An employee said that the lab got in the habit of using condensate (deionized water) for a blank, but he doesn’t

know why. He thinks it is because there are a lot of bubbles in the city water and that created a lot of problems

for the blank. (I 90a)

51. An employee said that he used condensate for the blank when he ran the tests for hydrazine. He never tested the

potable water for hydrazine. (I 76)

52. An employee stated that, when a reagent is added to a sample, one could see a yellowing of the sample at 10ppb

of hydrazine. (I 141)

53. Another employee stated that, when a reagent is added to a sample, one could see a yellowing of the sample at 5

to 10ppb of hydrazine. (I 90)

54. Another employee stated that, when he adds a reagent to a sample, he couldn’t see a yellowing at 5ppb; he

thinks that one can see a yellowing at about 20ppb, but admits that his memory is bad. (I 122)

55. There is a presumption in the test lab procedure (using city water as a blank) that city (potable) water contains

no hydrazine. (D-29)

56. A lab employee stated that the employees routinely took potable water samples to the lab for testing, but usually

the samples were from home. After the 8/15/89 discovery, employees would take plant water to the lab to be

tested on a regular basis. (I 90a)

The Effect of the Reagent on the hydrazine sampling

57. The PDMAB (reagent for testing hydrazine) can cause the blank to turn color. This is why you adjust the blank

to read zero in the test equipment. (D-29); (I-90a); (I-35a); (D-61)

58. An employee said that when you added a reagent to the blank sometimes it would turn different colors, without

hydrazine being in it. Over the years they would get a bad reagent. (I 90a)

59. An employee said that when using potable water for the blank, you would add the reagent and it would turn the

water a slight yellow color even if there was no hydrazine. There are different lot numbers on the reagent. The

color of the reagent would vary depending on the lot number of the reagent. Therefore, he concluded that you

wouldn’t be able to detect trace amounts of hydrazine. (I 35a).

Discussion:

Based upon the sampling data, the highest level of hydrazine discovered in the potable water was 15 ppb in the

water lab sink at 1330 hours on August 15, 1989. Based also on the sampling data, the highest levels of hydrazine

discovered in the ice, on August 22, 1989, was 17 ppb in the test group icemaker. It should be noted that all but

possibly three of the samples were taken after flushing of the potable water system began. For example, two of the

samples were taken of the ice, which was generated on 8/8/89. The third sample was collected on 8/14/89 most

likely prior to the flushing and was later sampled on 8/15/89. This flushing was begun on 8/14/89 on

recommendation of the East China Township water department. Although three different lab employees estimated

higher concentrations of hydrazine based upon their visual observations of samples taken just after lunch on August

15, 1989, they all had different recollections as to the color of the samples. The present day estimates that these

employees made as to the amount of hydrazine in the samples was based upon historical recollections of color; the

Team has not uncovered any notes or reports documenting these employees’ recollections back on August 15, 1989.

In any event, the highest sampled and documented level of hydrazine present in the HWHS between August 8, 1989

and August 15, 1989 was 238 ppb. There were no injections during this time period. In fact, the last time, prior to

8/15/89, that an injection of hydrazine was made into Unit 2 HWHS was May 23, 1989. Therefore, the Team has

determined that the maximum amount of hydrazine that could have been present in the HWHS between 8/8/89 and

8/15/89 was 238 ppb.

Based upon a consultant’s report, the oxygen in the potable water would have scavenged the hydrazine fairly

quickly. Though dilution and reaction rates would deplete any hydrazine in the water, the true levels of Hydrazine

at any point in the potable water system cannot specifically be determined. The Team has, therefore, concluded that

the levels of hydrazine that would have been consumed by employees in August of 1989 would be below 238 ppb,

which had been measured in the HWHS on 8/8/89.

Supporting Facts:

1. East China Township water department was contacted by a lab employee on 8/14/89 and informed that there

was a possible odor and taste problem with the plant’s drinking water. East China Township water department

advised this lab employee to flush the lines. (BT-12)

2. An employee’s notes prepared in August of 1989 state that in morning of 8/15/89, the potable water lines were

being flushed to get rid of bad taste. The notes further indicate that by 0930 hours the water was 97 degrees at

the cold water tap. (BT-65)

3. A lab employee stated that, on 8/15/89, hydrazine was discovered as a result of the lab trying to cool samples by

running cold water over them. (I 89) This same employee stated that two other lab employees told him that the

water in the lab was running warm, so he turned the water on and let it run. He further stated that after coming

back from lunch, he found the water was still running warm. (I 90) This employee stated that it was not

unusual for the lab water to run warm, but it was unusual for it not to cool off. (I 89)

Visual observations of hydrazine samples on 8/15/89:

4. This same lab employee stated that he conducted some tests on the potable water. First he found that the

conductivity was lower and the pH was elevated. He therefore ran a silica and a hydrazine test. With regard to

the hydrazine sample, the color of the sample when reagent was added was a light color, which he guessed to be

30 to 40 ppb. (I 90)

5. This lab employee stated that he next had two other lab employees conduct samples to confirm his finding. (I

90).

6. One of these other lab employees said that after adding reagent to the blank, the blank turned a dark yellow

color. It was not orange but darker that Wesson Oil. He did not know what the strength was. (I 97)

7. The other lab employee stated that when the reagent was added, it flashed. He further stated that the color was

a dark yellow or orange. He guessed that it was about 200 ppb. (I 35a)

8. The first lab employee said that he does not recall seeing any of the samples on 8/15/89 turn a dark yellow. (I

90a)

9. Two team members visited the SCPP water lab and observed that when the reagent is added to a solution of 100

ppb hydrazine, the sample turns a color close to the color of Wesson oil. (O-4)

Actual sampling data:

10. A Klett-Summerson colorimeter (1982 procedure), Spec 21 (1987 procedure) and Spec 20 (1991 procedure)

were used to calculate the amount of hydrazine in the water. (D-29)

11. When sampling the potable water, a lab employee stated that he remembers the natural color of the water, such

as rust in the water, causing some interference when reading a sample. The Spec 21 or Spec 20 would pick up

the natural color and give a false positive. (I 90a)

12. This water lab employee stated that bubbles in the water could also affect a reading of a sample. (I 90a)

13. A sample that was collected from the instrument shop drinking fountain on 8/14/89 revealed 2 ppb of hydrazine

in the potable water. (BT-11) The lab employee that took the samples stated that he thinks that this sample was

brought to the lab on 8/14/89, kept in the refrigerator and then sampled on 8/15/89. (I 90a)

14. The sampling at 1330 hours on 8/15/89 revealed 15 ppb of hydrazine in the water lab sink. (BT-11)

15. The sampling at 1330 hours on 8/15/89 revealed 3 ppb of hydrazine at the instrument shop sink. (BT-11)

16. The sampling at 1800 hours on 8/15/89 revealed 1-2 ppb of hydrazine at the Unit 2 ground floor men’s hot

water. (BT-11)

17. The sampling at 1800 hours on 8/15/89 revealed 1-2 ppb of hydrazine at the fountain in Document Control.

(BT-11) The employee that performed the sampling stated that, because this area is not well traveled, he thinks

this reading is a "false positive" based upon rust (or a natural color) in the water. (I 90a)

18. The sampling at 1200 hours on 8/16/89 was 1 ppb of hydrazine at Unit2 south turbine fountain. (BT-11) The

employee that performed the sampling stated that, because this area is not well traveled, he thinks this reading is

a "false positive" based upon rust (or a natural color) in the water. He thinks this is true especially because

when he resampled at 1500 hours on 8/16/89 the reading was 0 ppb of hydrazine. (I 90a)

18. The sampling at all other test points listed in (BT-11) on 8/15/89 and 8/16/89 indicated 0 ppb of hydrazine.

19. Three samples were taken of the ice at 1000 hours on 8/22/89 at the test group icemaker. The results were 17,8,

and 7 ppb of hydrazine. (BT-51)

20. The ice in the Clubhouse Icemaker and the Ball Field Icemaker was also sampled on 8/22/89. Although there

were original readings of 1 ppb of hydrazine, the water lab personnel determined that these readings were really

0 ppb because the natural color of the water interfered with the hydrazine reading. (BT-51)

21. On 8/22/89 at 1045 hours, an employee took two samples of ice that were generated two weeks previously

[which would be Tuesday, 8/8/89]. The results of those two samples were 0-1 ppb and 1-2 ppb of hydrazine. (I

90b and BT-51) Although (BT-51) does not specifically reference the date that the sampling was performed, the

employee that took the samples stated that the reference to "2 weeks" means that the ice was 2 weeks old as of

August 22, 1989. (I 90b) (See also BT-65, page 5)

22. On 8/22/89 at 1045 hours, an employee took one sample of ice that was generated two weeks and three days

previously [which would be Saturday, 8/5/89]. The result of that sample was 0 ppb of hydrazine. Although

(BT-51) does not specifically reference the date that the sampling was performed, the employee that took the

samples stated that the reference to "2 weeks and 3 days" means that the ice was 2 weeks and 3 days old as of

August 22, 1989. (I 90b)

23. On 8/22/89 at 1045 hours, an employee took one sample of ice that was generated two weeks and six days

previously [which would be Tuesday 8/2/89]. The result of that sample was 0 ppb of hydrazine. Although (BT-51)

does not specifically reference the date that the sampling was performed, the employee that took the

samples stated that the reference to "2 weeks and 6 days" means that the ice was 2 weeks and 6 days old as of

August 22, 1989. (I 90b)

24. On 8/22/89 at 1045 hours, an employee took two samples of ice that were generated one month previously

[which would be 7/22/89]. The results of both of those samples were 0 ppb. Although (BT-51) does not

specifically reference the date that the sampling was performed, the employee that took the samples stated that

the reference to "1 month" means that the ice was I month old as of August 22, 1989. (I 90b).

25. Once the contamination was discovered on 8/15/89, the highest concentration measured per (BT-6) was 15 ppb

at 1330 hours.

hours.

The Hot Water Heating System:

27. The normal source of water for the Service Building HWHS is connected to Unit 2 HWHS. (D-18)

28. An employee’s notes indicate that, on 8/15/89, the S.B. HWHS was valved into Unit 2 HWHS and the

hydrazine concentration was 128 ppb. (BT-66)

29. Cooling and Heating Water System Analysis ("CHWSA") sheets are used by water lab personnel to measure

the ph, conductivity and hydrazine levels in the Closed Cooling Water and Hot Water Heating Systems. (BT-34)

30. CHWSA sheets indicate a range of 50 to 500 ppb of hydrazine to be maintained in the HWHS. (BT-34)

31. An employee stated that when injecting hydrazine into the HWHS, a water lab employee would ask the

operators to run the hydrazine pump. The pumps did not necessarily run the length of time indicated on the

sample sheets. That is why there would be spikes in the level of hydrazine in the HWHS water when it looks

like the operator ran the pump for a short time period. (I 35a)

32. CHWSA sheets (8/88 –8/89) indicate hydrazine sampling was done weekly. (BT-34)

33. CHWSA sheets (8/88-8/89) indicate there was no hydrazine injection treatment done in the Unit 2 HWHS from

5/23/89 through 8/29/89. (BT-34)

34. On 8/8/89, hydrazine was sampled at 238 ppb in the Unit 2 HWHS. No treatment was done. (BT-34)

35. On 8/15/89, hydrazine was sampled at 128 ppb in the Unit 2 HWHS. No treatment was done. (BT-34)

36. On May 23, 1989, the hydrazine reading in Unit 2 HWHS was 2 ppb. Hydrazine was injected for 45 minutes.

The next week, on June 6, 1989, the hydrazine reading in Unit 2 HWHS was 372 ppb. After June 6, 1989, the

hydrazine levels continued falling. Hydrazine was not injected again into Unit 2 HWHS until sometime after

8/15/89, the date that the cross connection was dismantled. (BT-34)

The effects of hydrazine entering potable water

37. Hydrazine is a reducing compound used to reduce corrosion by reacting with and thus removing dissolved

oxygen. (C-5)

38. The concentration of dissolved oxygen in processed river water (potable water) used at Belle River Power Plant

is 8,000 ppb. (I 141)

39. A chemical engineer at St. Clair Power Plant stated that a hydrazine and oxygen reaction results in nitrogen gas

and water. The ambient temperature of the potable water would result in a slow reaction rate; the reaction rate

is higher with higher temperatures. In fact, reaction rates double for every 10 degrees of temperature. There is

a greater reaction rate with 8,000 ppb of oxygen and, for example, 200 ppb of hydrazine than with 200 ppb of

hydrazine and 200 ppb of oxygen. (C-5) (I 141)

40. R.A Nearhoof, General Supervisor – Chemistry at Fermi II prepared an opinion on the introduction of hydrazine

into potable water from a chemistry perspective. The opinion, which the Team received January 8, 2003,

contains the following information: Hydrazine is a reducing agent that removes dissolved oxygen. When

hydrazine reacts with Oxygen, it produces water and nitrogen gas. The report further provides that, in practice,

1.5 to 2.0 parts of hydrazine are required per part of oxygen to totally consume all of the dissolved oxygen.

Potable water is an air saturated system and typically has 8000 ppb of oxygen. The opinion further provides

that any levels in the potable water system with the dilution factors involved would be negligible. (I 128; C-3)

41. A chemist from GE Betz confirmed Nearhoof’s analysis and added that copper acts as a catalyst in the

hydrazine/oxygen scavenging reaction, which means that a significant portion of hydrazine would have been

consumed through the reaction with oxygen in the potable water. (C-4)

42. A consultant report prepared on 2/14/03 by Mike Bennett states that several factors combine and influence a

hydrazine concentration within the potable water system and the hydrazine concentration that may be observed

at the point of potable water usage. It further states that regardless of whether the factors exist individually or

are combined, the factors cause a lower hydrazine concentration to be observed at the point of potable water

usage when compared to the concentration observed in the HWHS. (C-7).

Discussion:

Seventy-five (75) samples of the potable water were taken from 8/14/89 through 8/22/89. (BT-11, BT-51) Of these

samples, five (5) were taken in the Administration Building, one (1) was taken from the Main Gate House, one (1)

was taken from the Clubhouse, twenty-two (22) were taken in the Commons area, four (4) were taken in the

Document Control Building, one (1) was taken in the Garage, fourteen (14) were taken in the Service Building, ten

(10) were taken in Unit 1 Power block, seven (7) were taken in Unit 2 Power Block, four (4) were taken in Fuel

Supply-TH 7, one (1) was taken in the Warehouse B, one (1) was taken from Warehouse C and one (1) was taken

from the Ballfield. (See Conclusion #6) Sixty-four (64) of the samples taken read 0 ppb. Eleven (11) samples

taken indicated that hydrazine was found in the potable water system in the Unit 2 ground floor men’s hot water tap,

in the water lab and in the instrument shop sink and fountain in the Commons area. Hydrazine was also discovered

in the ice in the test group icemaker and freezer on the ground floor near the plant air compressors.

By reviewing P&IDs and site drawings of the potable water system at Belle River and the sample sheet (Cooling &

1989, the team concluded that the documented contamination was limited to the Unit 2 Power Block and the

Commons area. (See Conclusion #6 for details of plant sites not affected) The actual physical potable water system

piping flow path was verified by Observation #16.

Supporting Facts:

Actual sampling data:

1. A sample that was collected from the instrument shop drinking fountain on 8/14/89 revealed 2 ppb of hydrazine

in the potable water. (BT-11) The water lab employee that took the samples stated that he thinks that this

sample was brought to the lab on 8/14/89, kept in the refrigerator and then sampled on 8/15/89. (I 90a)

2. The sampling at 1330 hours on 8/15/89 revealed 15 ppb of hydrazine in the water lab sink. (BT-11)

3. The sampling at 1330 hours on 8/15/89 revealed 3 ppb of hydrazine at the instrument shop sink. (BT-11)

4. The sampling at 1800 hours on 8/15/89 revealed 1-2 ppb of hydrazine at the Unit 2 ground floor men’s hot

water. (BT-11)

5. The sampling at 1800 hours on 8/15/89 revealed 1-2 ppb of hydrazine at the fountain in Document Control.

(BT-11) The employee that performed the sampling stated that, because this area is not well traveled, he thinks

this reading is a "false positive" based upon rust (or a natural color) in the water. (I 90a)

6. The sampling at 1200 hours on 8/16/89 was 1 ppb of hydrazine at Unit2 south turbine fountain. (BT-11) The

employee that performed the sampling stated that, because this area is not well traveled, he thinks this reading is

a "false positive" based upon rust (or a natural color) in the water. He thinks this is true especially because

when he resampled at 1500 hours on 8/16/89 the reading was 0 ppb of hydrazine. (I 90a)

7. Three samples were taken of the ice at 1000 hours on 8/22/89 at the Test Group icemaker. The results were 17,

8, and 7 ppb of hydrazine.

8. The ice in the Clubhouse icemaker and the Ball Field icemaker was also sampled on 8/22/89. Although there

were original readings of 1 ppb of hydrazine, the lab determined that these readings were really 0 ppb because

the natural color of the water interfered with the hydrazine reading. (BT-51)

9. On 8/22/89 at 1045 hours, an employee took two samples of ice from the Test Group freezer that were

generated two weeks previously [which would be Tuesday, 8/8/89]. The results of those two samples were 0-1

ppb and 1-2 ppb of hydrazine. (I 90b and BT-51) Although (BT-51) does not specifically reference the date that

the sampling was performed, the employee that took the samples stated that the reference to "2 weeks" means

that the ice was 2 weeks old as of August 22, 1989. (I 90b) (See also BT-65, page 5).

Engineering Analysis

10. An engineering study Belle River Hydrazine Contamination of the Potable Water, dated 1/28/03, requested by

the Team and performed by Arthur Zwierzchowski of the Engineering Support Organization studied the

backflow possibilities to the potable water system if it was cross connected to the HWHS. (C-6)

11. P&ID M-0016, sheet 3 includes a handwritten sketch of the "as found" (on 8/15/89) cross connection hose and

a written list of various locations in the plant and fuel supply that are fed from the 100 pound potable water leg.

(I 91a)

12. The cross connection was made between the Service Building Potable Water Booster Pump Station and the

Electric Water Heating Tank located in the Service Building (Case 1) (C-6)

13. The cross connection was made between the Service Building Potable Water Booster Pump Station and

downstream of valve 005 (DECo. Drawing 6M1258-0017 area E-3 and upstream of condenser test connection

(DECo. Drawing 6M1258-0017-2 Area A-7) (Case 2) (C-6)

14. Boiler building 1 and 2 and the service building are shown on D-6, P&ID drawing M-0017.

15. Appendix E is a drawing showing the buildings that were impacted by hydrazine.

Discussion:

Sixteen samples (BT 11, BT 51) were taken from 8/14/89 through 8/22/89 in the Administration Building, the Main

GateHouse, Warehouse C, the Document Control Building, Warehouse B, the Clubhouse and the Garage. (See

Appendix ‘E’, Site Building Drawing) Fourteen readings were 0 ppb. Two readings (clubhouse and ball field

icemakers) tested at 1 ppb and then immediately resampled at 0 ppb. The original readings were believed to be

invalid because of rust in the samples.

Team examination of P&ID M-0017 sheet 1 shows that for the Administration Building, the Gate House, the

Combination Shop (Warehouse ‘C’), the Construction Office Building (Document Control), the Construction

Warehouse (Warehouse ‘B") and the B&W Warehouse (Activities Building/Clubhouse), the potable water supply 

The Ash Unloading building has no potable water so it was unaffected by the hydrazine.

According to the engineering study performed by A. Zwierzchowski, even if the check valves failed, there would be

insufficient pressure and too much distance for the water in the H.W.H.S. to reach the Administration Building and

the other out buildings.

Supporting Facts:

by the Team and performed by Artur Zwierzchowski of the Engineering Support Organization studied the

backflow possibilities to the potable water system if it was cross connected to the HWHS. The study concluded

there was a zero probability for back flow to the Administration Building and other outbuildings [Main Gate

House, Combination Shop (Warehouse C), Construction Office Building (Document Control), Construction

Warehouse (Warehouse B), B&W Warehouse (Activities Building/Clubhouse), Change House (pipe shop) and

the Garage (reference drawing 6M1258-1923).

2. Potable water lines do not run to the Ash Unloading building, only bottled water is used. (D-6)

3. Hydrazine in the potable water system did not enter the Administration Building. The Administration Building

supply line is upstream of the Service Building potable water booster pumps and check valves. (P&ID M-0017,

sheet 1) (D-6)

4. The sampling at 1800 hours on 8/15/89 was 0 ppb at an Administration Building sink. (BT-11, sheet 1)

5. The sampling on 8/15/89 was 0 ppb at men’s shift supervisor locker room water hot in the Administration

Building. (BT-11, sheet 2)

6. The sampling on 8/15/89 was 0 ppb at men’s shift supervisor locker room water cold in the Administration

Building. (BT-11, sheet 2)

7. The sampling on 8/15/89 was 0 ppb at men’s tech. locker room water hot in the Administration Building. (BT-11,

sheet 2)

8. The sampling on 8/15/89 was 0 ppb at men’s tech. locker room water cold in the Administration Building. (BT-11,

sheet 2).

9. Hydrazine in the potable water system did not enter the Main GateHouse. The Main GateHouse supply line is

upstream of the Service Building potable water booster pumps and check valves. (P&ID M-0017, sheet 1)

10. The sampling at 1800 hours on 8/15/89 was 0 ppb at the GateHouse fountain. (BT-11, sheet 1)

11. Hydrazine in the potable water system did not enter the Combination Shop (Warehouse ‘C’). The Combination

Shop (Warehouse ‘C’) supply line is upstream of the Service Building potable water booster pumps and check

valves. (P&ID M-0017, sheet 1)

12. The sampling at 1400 hours on 8/16/89 was 0 ppb at a Warehouse C sink (south side). (BT-11, sheet 3)

13. Hydrazine in the potable water system did not enter the Construction Office Building (Document Control). The

Construction Office Building (Document Control) supply line is upstream of the Service Building potable water

booster pumps and check valves. (P&ID M-0017, sheet 1)

14. The sampling at 1800 hours on 8/15/89 was 1 to 2 ppb at Document Control. (BT-11) A lab employee said that

he thinks that this reading is a false positive because of natural color in the water, such as rust, which causes

interference with the reading of the Spec 20 and Spec 21. This employee further said that in certain areas, such

as the document control area and the south turbine fountain where there is not a lot of use of the water, a rust

color could develop in the water. Bubbles in the water can also affect the reading. (I 90a)

15. The sampling at 0830 hours on 8/16/89 was 0 ppb at west men’s bathroom hot in Document Control. (BT-11,

sheet 4)

16. The sampling at 0830 hours on 8/16/89 was 0 ppb at east men’s bathroom hot in Document Control. (BT-11,

sheet 4)

17. The sampling at 0830 hours on 8/16/89 was 0 ppb at center drinking fountain in Document Control. (BT-11,

sheet 4)

18. The sampling at 0830 hours on 8/16/89 was 0 ppb at east drinking fountain in Document Control. (BT-11,

sheet 4)

19. Hydrazine in the potable water system did not enter the Construction Warehouse (Warehouse ‘B’). The

Construction Warehouse (Warehouse B) supply line is upstream of the Service Building potable water booster

pumps and check valves. (P&ID M-0017, sheet 1)

20. The sampling at 1400 hours on 8/16/89 was 0 ppb at the Warehouse B sink. (BT-11, sheet 3)

21. Hydrazine in the potable water system did not enter the B&W Warehouse (Activities Building/Clubhouse). The

B&W Warehouse (Clubhouse) supply line was upstream of the Service Building potable water booster pumps

and check valves. (P&ID M-0017, sheet 1)

22. The sampling at 1800 hours on 8/15/89 was 0 ppb at the Clubhouse, men’s restroom cold. (BT-11, sheet 1)

23. The sampling at 1030 hours on 8/22/89 was 1 ppb at the Clubhouse icemaker, but resampled 0 ppb "because the

natural color in water interfered with the N2H4 reading." (BT-51)

24. Hydrazine in the potable water system did not enter the garage (location listed as "maintenance shops" on P&ID

M-0017, sheet 1, but now used as a garage). The garage supply line was upstream of the Service Building

potable water booster pumps and check valves. (P&ID M-0017 sheet 1.)

25. The sampling at 1400 hours at 8/16/89 was 0 ppb at the garage sink. (BT-11, sheet 3)

26. Hydrazine in the potable water system did not enter the Change House (currently called the pipe shop). The

Change House supply line was upstream of the Service Building potable water booster pumps and check valves.

Supply line was upstream of the Service Building potable water booster pumps and check valves.

Discussion:

All documentation and employee interview statements are consistent on this issue. Once the cross connection was

discovered on 8/15/89, immediate action was taken to disconnect the cross connection so that no more

contamination could enter the potable water system. There are no interview statements or documentation that

contradict this conclusion.

Supporting Facts:

1. The cross connection was discovered and isolated on 8/15/89. (I 89, I 123,) (BT-4)

2. Another employee stated that after he saw the cross connection on 8/15/89, he told a second employee to

close the valve to the potable water. He also stated that he took action to shut down the cross connection. (I

89)

3. The 8/15/89 "Shift Supervisor’s Watch Report" (day shift) stated that the source of the hydrazine was

eliminated. (BT-54)

4. The garden hose was removed on 8/15/89 based on WO #239483 at (BT-3).

5. WO #40539? requested to "Remove and Cap the Potable H2O Line to HVAC Room above Maintenance

Bullpen Area". The job was completed on 8/16/89. (BT-3)

6. The 8/15/89 Unit 2 "Shift Watch Report" (night shift) indicates that maintenance completed work on an

HVAC H2O line. (BT-53)

7. A 8/21/89 safety report entitled "Belle River-Water Contamination Report" prepared by D. Fitzgerald

indicates that, upon discovery of the cross connection, everything was valved out and the hoses removed

and discarded. (BT-63).

Discussion:

The date that the hydrazine was removed from the potable water is well documented both in memos and in the

sampling data. On 8/15/89, the shower and wash water was released for use. After this date, East China Township

performed additional testing for bacteria to make sure that the potable water was safe for consumption. No

information was discovered which contradicts that the hydrazine was removed from the potable water the evening of

8/15/89.

Supporting Facts:

1. The Night Shift Watch Report for 8/15/89 stated that all points were free of Hydrazine. (BT-55)

2. An 8/16/89 Memo from Jim Kelly to the personnel stated that all points were free of hydrazine as of the

evening of 8/15/89. (BT-8)

3. The sample sheet indicates that as of 1800 hours on 8/15/89 all locations tested 0 ppb with the exception of

one hit of 1 ppb at the Unit II Ground Floor Men’s Lavatory. (BT-11)

4. The Notes at BT-66 indicate that at 8 or 9 p.m. on 8/15/89, the shower and wash water was released for use.

No free chlorine or hydrazine.

5. The sample sheet for 8/16/89 indicates 0 ppb at all locations tested. (BT-11) Although the sampling at

1200 hours on 8/16/89 was 1 ppb of hydrazine at Unit2 south turbine fountain, the employee that

performed the sampling stated that, because this area is not well traveled, he thinks this reading is a "false

positive" based upon rust (or a natural color) in the water. He thinks this is true especially because when he

resampled at 1500 hours on 8/16/89 the reading was 0ppb of hydrazine. (I 90a)

6. The potable water is released for normal use (i.e. consumption) on August 20, 1989. (BT-14)