05000237/FIN-2007004-03
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Finding | |
|---|---|
| Title | Inadequate Reactor Operators Shift Turnover |
| Description | The inspectors identified a performance deficiency involving a Severity Level IV Violation of Technical Specification (TS) 5.4.1 for the failure of two Nuclear Station Operators (NSOs) to follow station procedures during shift turnover. The licensees corrective actions for this issue included: 1) the Unit Supervisor had an alternate operator relieve the on-coming operator involved with improper turnover, 2) the licensee convened a fact finding investigation to determine the facts of the event, 3) the licensee increased the awareness of the operators at the facility to the importance of proper shift turnover, and 4) the licensee took disciplinary action toward the two individuals. Description: On January 16, 2007, the inspectors observed an abbreviated shift turnover between the on-coming and off-going NSOs, licensed reactor operators, at the NSO work station at Dresden Power Station, Unit 2. The inspectors observed the on-coming operator enter the control room approximately 15 minutes after normal shift turnover, the on-coming operator spoke briefly with the off-going operator, and the off-going operator exited the control room. At the time of this event, Unit 2 was in an elevated risk profile (yellow) due to various plant components, such as the 2C and 2D containment cooling service water pumps and the 2C and 2D low pressure coolant injection pumps, being out of service. The inspectors questioned if the turnover could have been sufficient to allow the on-coming operator to gain the appropriate level of knowledge of plant status for safe operations and communicated this observation to the on-duty Unit 2 Supervisor. The Unit 2 Supervisor had the on-coming operator relieved by another qualified operator and commenced a fact finding investigation into the matter. Both operators were questioned, individually, within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the event to determine to what extent they performed shift turnover. Verification of the card reader transaction history report for the control room door showed that the two operators were in the control room for less than three minutes together during their shift turnover. This issue was referred to the NRC Office of Investigations (OI) due to potential wrongdoing. (OI Report 3-2007-009) During various interviews, including the licensees fact finding investigation and OI interviews, the on-coming operator stated that: 1) he did not perform a panel walk down of the control room back panels and common panels associated with the unit; 2) he did not review the operating logs for the unit prior to turnover; 3) he did not tour the main control panels for the unit with the off-going operator; and 4) he did not discuss all the information regarding the unit status with the off-going operator. The on-coming operator indicated to the Shift Operations Superintendent that he knew this did not constitute a proper shift turnover, but the operator felt this was acceptable since he was on shift eight hours previously and had a firm understanding of plant conditions. The 26 Enclosure on-coming operator also stated that this decision was due to his late arrival to the control room and that he made a bad decision. The inspectors concluded that the NSO shift turnover was inadequate and did not comply with the requirements in operating procedure OP-AA-112-101, Shift Turnover and Relief. Specifically, Section 3.1 requires that, All shift personnel are responsible for reviewing and understanding the logs, checklist and turnover sheets applicable to their shift position before assuming the shift, Section 3.2 requires that, the off-going operator shall not leave his/her work area until he/she is satisfied that his/her relief is fully aware of existing conditions, and Section 4.1.3 requires shift personnel to, VERIFY important operating parameters, especially those relating to safety systems, as identified on the turnover sheet prior to assuming the shift. Additionally, Operator Aid #159, Nuclear Station Operator Turnover Checklist, further outlines the requirements of the operating procedures, including for example, the on-coming NSO must read the control room logs, tour main control panels, tour main control room back and common panels, and discuss system status with the off-going operator. Shift turnover provides power plant operators with the appropriate level of knowledge of plant conditions and system configurations to allow safe operation of the reactor core and support systems. Operators are required to react to postulated accident scenarios in order to help mitigate predicted consequences. Insufficient knowledge of plant status increases the likelihood that an operator could perform an error of commission/omission which could magnify the consequences resulting from postulated accident scenarios or potentially introduces additional initiating events through incorrect equipment manipulations. At the time of this event, Unit 2 was in an elevated risk profile (yellow) due to various plant components. This increased risk profile amplified the importance of knowing and understanding plant conditions. Therefore, inadequate shift turnovers unnecessarily increase the risk to public health and safety. The inspectors supported by the regional staff determined that the licensed operators knew the requirements to be followed during shift turnover at the NSO work station based upon their extensive work experience and the testimonies given during the licensees fact finding investigation. The OI investigation report concluded that the operators deliberately failed to perform shift turnover and relief procedure requirements. Failure to follow these requirements was a willful act promoted by the on-coming operator arriving late in the control room. Analysis: The inspectors and the regional office staff concluded that there was no Significance Determination Process finding associated with this case. Because this performance deficiency involved a willful act, this issue was dispositioned using the traditional enforcement process instead of the Significance Determination Process. The violation of TS 5.4.1 was categorized in accordance with the NRC Enforcement Policy. The failure to follow the shift turnover procedure, absent willfulness, had no actual safety consequences, and constitutes a minor violation. Considering willfulness on part of the operators, a Severity Level IV violation is warranted. The violation is being cited because it was willful and was identified by the NRC. Enforcement: Dresden Nuclear Power Station, Unit 2, Technical Specification (TS) 5.4.1 states, in part, that written procedures shall be established, implemented, and 27 Enclosure maintained covering the applicable procedures recommended in Regulatory Guide 1.33, Revision 2, Appendix A, dated February 1978. Regulatory Guide 1.33, (1)(g) states that a typical safety-related activity that should be covered by written procedures is shift and relief turnover. Dresden Nuclear Power Station uses operating procedure OP-AA-112-101, Shift Turnover and Relief, and Operator Aid #159, Nuclear Station Operator (NSO) Turnover Checklist, to meet TS 5.4.1 at the NSO position. Operating procedure OP-AA-112-101, Section 3.1, requires that, all shift personnel are responsible for reviewing and understanding the logs, checklist and turnover sheets applicable to their shift position before assuming the shift. Section 3.2 requires that, the off-going operator shall not leave his/her work area until he/she is satisfied that his/her relief is fully aware of existing conditions. Section 4.1.3 requires shift personnel to, VERIFY important operating parameters, especially those relating to safety systems, as identified on the turnover sheet prior to assuming the shift... Operator Aid #159 requires the on-coming NSO to perform the following before relieving shift: READ control room logs from last date on-shift or previous four days, whichever is less. DISCUSS with off-going NSO all items on unit and common turnover sheets, shift and daily surveillances, and any other pertinent information. TOUR main control panels and DISCUSS: Status of safety related systems, Running equipment and safety train alignments, Inoperable equipment, including instrumentation, LCORAs [limiting condition for operation required action], including surveillance requirements, Reasons for annunciator alarms, C/O [clearance order] and surveillance work in progress, and Abnormal events over past 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. TOUR main control room back panels. TOUR main control room common panels. Contrary to the above, on January 16, 2007, two NSOs failed to perform a proper shift turnover and relief at Dresden Unit 2 when the operators did not comply with operating procedure OP-AA-112-101 and Operator Aid # 159. Specifically, the on-coming operator did not read the control room logs for the last date on-shift, did not tour the main control room back panels, and did not tour the main control room common panels. The on-coming and off-going operators did not tour the main control panels, and did not discuss all the information regarding unit status. The off-going operator left the work area without the on-coming operator being fully aware of existing conditions. A Notice of Violation (NOV) was issued (VIO 05000237/2007004-03). See Enclosure 1 of this Inspection Report. The NRC has concluded that information regarding the reason for the violation, the corrective actions taken and planned to correct the violation and prevent recurrence and the date when full compliance was achieved is already adequately addressed in this report and this violation is closed |
| Site: | Dresden  |
|---|---|
| Report | IR 05000237/2007004 Section 4OA5 |
| Date counted | Sep 30, 2007 (2007Q3) |
| Type: | TEV: Severity level IV |
| cornerstone | No Cornerstone |
| Identified by: | NRC identified |
| Inspection Procedure: | |
| Inspectors (proximate) | B Dickson M Sheikh W Slawinski C Phillips R Schulz J Mcghee A Koonce |
| INPO aspect | |
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Finding - Dresden - IR 05000237/2007004 | |||||||||||||||||||||||||||||
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Finding List (Dresden) @ 2007Q3
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