05000309/LER-2012-001
| Docket Numbersequential Revmonth Day Year Year Month Day Yearnumber No. 05000 | |
| Event date: | |
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| Report date: | |
| 3092012001R00 - NRC Website | |
On January 12, 2012 the Maine Yankee Independent Spent Fuel Storage Installation (ISFSI) was in steady state "Storage Operations" as defined in NAC-UMS Technical Specifications. On the evening shift, environmental effects of a snow storm was causing issues with the Protected Area (PA) Isolation Zone (IZ) Intrusion Detection System (IDS). The evening shift security force bypassed a zone of the IDS and instituted compensatory measures that were not fully effective for the intended purpose. The oncoming night shift security force identified the problem and immediately implemented fully effective compensatory measures. The sequence of events timeline is as follows:
1646 - Security IDS equipment bypassed due to environmental factors and compensatory measures instituted that were not fully effective for the intended purpose.
1934 - One of the CCTV cameras providing compensatory measures was identified to be not correctly positioned by the Central Alarm Station Operator (CASO). The CCTV camera was repositioned by the CASO; however, it still did not provide a fully effective assessment of the bypassed IDS zone. The CASO did not notify the ISS or comply with procedural requirements for compensatory measures.
2213 - Oncoming Central Alarm Station Operator (CASO) assumes the watch and determines that compensatory measures are not fully effective. The oncoming ISFSI Shift Supervisor (ISS) immediately directs the establishment of effective compensatory measures.
2221 - Effective compensatory measures were established. Protected Area was inspected with no evidence of unauthorized access.
2245 - G4S and Maine Yankee management notified.
2300 - Maine Yankee management representative arrives onsite.
2321 - Security IDS equipment was tested and returned to service. Compensatory measures were secured.
2400 - Management completed a review of the event, including procedural and reportability guidance.
0050 - One-hour reportable event notification made to the NRC Operations Center under 10 CFR 73.71(b)(1) for safeguards events as described in Appendix G, paragraph 1(c) for an uncompensated degradation in a safeguards system that could allow unauthorized or undetected access to a protected area (NRC Operations Center Event #47588).
0135 - NRC Region 1 notified of the event via voice mail and e-mail.
0137 - Maine State Nuclear Safety Inspector notified of the event via voice mail and e-mail.
Approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and 48 minutes into the event, the CASO recognized the CCTV camera was mispositioned and took steps that he believed would implement the required compensatory measures; however, the individual failed to notify management and ultimately did not establish a fully effective compensatory measure. This was a missed opportunity for the onshift crew to identify and resolve the issue earlier in the event timeline.
The affected security IDS zone did not have fully effective compensatory measures for 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> and 35 minutes; however, there were other mitigating circumstances. The evening shift security force had established compensatory measures using CCTV Pan-Tilt-Zoom (PTZ) cameras on dedicated monitors. During the entire duration of the event, fixed CCTV cameras were in service allowing full assessment of the bypassed IDS zone. These cameras were in a cycling sequence mode being displayed on security monitors.
The event investigation involved onsite Maine Yankee and G4S management and independent assessments from Connecticut Yankee ISFSI personnel and the Maine Yankee QA Representative. This event was entered into the Maine Yankee Corrective Action Program and a Barrier Screen was initiated to determine failed or missing barriers (causes) and to provide corrective actions to prevent recurrence.
Failed or Missing Barriers/Causes:
1) Procedures lacked specific details on compensatory measures.
2) Training program was not fully effective.
3) Expectations were not delineated in procedures.
4) Accountability issues existed for personnel involved (Human Performance and Procedural Compliance).
The following corrective actions have been taken or are planned to prevent recurrence:
Initial Corrective Actions:
1) Fitness for Duty was evaluated.
2) Retraining of personnel involved was conducted.
3) Disciplinary action was taken.
Short Term Corrective Actions:
1) Enhancing procedures.
2) Making fundemental changes to the Training Program.
3) Providing additional training and retraining in a variety of areas.
4) Formalizing expectations.
5) Evaluating security team makeup.
6) Independent assessing of the event.
7) Reviewing of historically significant events.
8) Developing a Lessons Learned document.
9) Conducting security personnel interviews with management.
10) Re-evaluating the philosophy regarding compensatory measures.
Long Term Corrective Actions:
1)Conduct benchmarking and self assessments.
2) Perform a QA audit evaluation for the effectiveness of corrective actions.
Investigation of this event identified human performance related elements that occurred during the initial establishment of compensatory measures. These included personnel errors and or mental lapses involving attention to detail, procedural compliance and supervisory oversight. During the event, there were missed opportunities to correct the mispositioned CCTV camera; however, due to a failure in personnel performance, communications, and procedural compliance the not fully effective compensatory measures went unnoticed until the oncoming shift arrived for turnover. Additionally, the event could have been mitigated if the evening shift had more aggressively implemented the Snow Removal Plan to allow placing the IDS back in service.
Information concerning this event has been provided to NRC Region 1 and Maine State Nuclear Safety Inspector. There has been no media interest or press releases made . Maine Yankee made 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> reports in April and November of 2007 pursuant to 10 CFR 73.71(b)(1) for security related events. These reportable events had different circumstances; however, share common similarities in the failed barriers or causes, which include procedural compliance, security force member knowledge level and retention of training, specific procedural guidance, communications, supervisory oversight, and elements of human performance.
Contact person for further information:
James Connell Vice President Maine Yankee Atomic Power Company 321 Old Ferry Road Wiscasset, Me 04578 (207) 882-1303 jconnell@3yankees.com