IR 05000220/1989013
| ML17056A146 | |
| Person / Time | |
|---|---|
| Site: | Nine Mile Point  |
| Issue date: | 07/26/1989 |
| From: | Conte R, Cook W, Florek D, Gallo R, Howe A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17056A145 | List: |
| References | |
| 50-220-89-13, CAL-88-17, NUDOCS 8908020343 | |
| Download: ML17056A146 (62) | |
Text
U.S.
NUCLEAR REGULATORY COMMISSION
REGION I
Report No.
License No.
Licensee:
50"220/89-13 DPR"63 Niagara Mohawk Power Corporation 301 Plainfield Road Syracuse, New York Facility Name:
Nine Mile Point Unit
Inspection Conducted:
May 22-25, 1989 Inspectors:
A. Howe, Sr. Operations Engineer Date D. Florek, Sr.
perations ngineer Date W. Cook, Sr. Resident Inspect r Date Reviewed by:
R.
Co e, Chief, BWR Section Operations Branch, DRS Date Approved by:
Robert M. Gal
, Chief Operations Branch Division of Reactor Safety Date Executive Summar
This was a special announced inspection which assessed the Nine Mile Point Unit 1 operator proficiency and use of facility procedures, primarily Emergency Operating Procedures, during emergency situations/transients.
This inspection assessed the performance of the Nine Mile Point Unit 1 on-shift operating crews using NRC developed scenarios on the Nine Mile Point Unit 1 plant specific simulator.
No violations or deviations were identified.
There was improved operator proficiency in the use of the Emergency Operating Procedures from a previous inspection in this area.
Five of six crews were determined to be satisfactory.
890S0P034<
+>072 PDR AGOCK 050002 '0 l.l PDC
All six Station Shift Supervisors (SSS)
and Assistant Station Shift Supervisors (ASSS) were determined to be satisfactory.
However, the SSS and ASSS for the crew, which was not considered satisfactory, demonstrated individual weaknesses that were considered as part of the crew evaluation rather than individually.
In addition, one Chief Shift Operator for one of the crews, which was consi-dered satisfactory, demonstrated individual weaknesses.
Weaknesses were also identified regarding crew communications and crew duties, assignments, and responsibilities.
Additional weaknesses were identified in the use of selected facility procedures.
The crew and individual who did not demonstrate satis-factory performance wi 11 require reassessment prior to power operation.
The NRC may also assess an additional crew(s) to determine if actions relative to the weaknesses were effectiv DETAILS 1.0 PERSONS CONTACTED AND STATION SHIFT SUPERVISORS of the CREWS EVALUATED Licensee representatives 4+
¹¹*
¹*y
¹*
+
¹8'~
¹*y
¹*y
- +
M. Bandla, Assistant Superintendent Operations C.
Beckham, Manager NQAO G. Brownell, Regulatory Compliance J.
Bunyen, Assistant Manager L. Burkhardt, Executive Vice president Nuclear J. Burton, Supervisor NQAO Surveillance M. Colomb, Regulatory Compliance K. Dahlberg, Station Superintendent Unit
A. Denny, ISEG J. Earls, SSS of Crew C
L. Fenton QA Lead Auditor G. Holthouse, SSS of Crew A J. Jordan, Attorney D. Lilly, SSS of Crew R
P.
MacEwan, NYSEG J. Parrish, SSS of Crew E
M. Peifer, Manager Nuclear Services M. Peterson, Training N. Rademaker, Executive Assistant R. Randall, Operations Superintendent R.
Remus, Superintendent Chemistry/Radiation A. Rivers, Superintendent Training R. Sanaker, Training R. Seifried, Assistant Superintendent Training G. Shelling, SSS of Crew B
M. Stancliffe, SSS of Crew D
M. Thomas, OD Consultant J. Willis, General Superintendent Operations U.S Nuclear Regulatory Commission
¹"+
R. Conte, Chief BMR Section, Operations Branch
¹ R. Gallo, Chief Operations Branch, DRS
+
R. Laura, Resident Inspector
¹ +
R.
Temps, Resident Inspector p
¹ Denotes those who participated in the telephone conducted exit on June 1,
1989.
- Denotes those present at the interim exit on May 25, 1989.
+ Denotes those persons who observed the NRC assessment process at times at the Nine Mile Point Unit 1 simulato.0 OVERVIBI OF INSPECTION Inspection Report 50-220/88-22 identified that the operating staff was unable to use the Emergency Operating Procedure (EOP) flow charts.
Deficiencies were observed in three areas:
an apparent misunderstanding regarding emergency opera-ting concepts, procedure adherence and the use of the procedures.
In addition, teamwork and communication skills, as well as recognition of emergency system status and degraded plant conditions, were also identified as weaknesses observed during the inspection.
The licensee in a letter dated August 12, 1988, responded to the inspection findings and also identified that actions to correct EOP and operator training deficiencies will be further addressed in the action plan for Unit 1 restart in response to CAL 88-17.
The NRC in a letter dated March 24, 1989, made arrangements for an NRC assess-ment of operator proficiency, provided that the facility senior management indicate in writing that the Unit-1 operators have achieved the desired level of proficiency in using the facility procedures.
The NRC evaluation would not only emphasize EOP implementation, but also the implementation of Emergency Action Procedures (EAP.'nd Emergency Plan Implementation Procedures (EPP).
In a letter dated May 19, 1989, the facility provided senior management endorse-ment of operator proficiency in the use of facility procedures and formally requested that the NRC conduct assessments of the Nine Mile Point Unit
operators in this area.
The NRC conducted the assessment of Nine Mile Point Unit-1 operator proficiency and use of facility procedures during the week of May 22, 1989.
The NRC developed scenarios to use on the Nine Mile Point Unit-1 simulator to determine if weaknesses previously identified had been corrected.
The NRC verified the adequacy 'of the scenarios prior to use with the assistance from two facility representatives from training and one facility representative from operations.
These individuals also assisted in or operated the simulator during the NRC assessments and signed security agreements for the period of the NRC assess-ments stating that they would not divulge the contents of the simulator scenar-ios or participate in any training or warm up scenarios with the operating crews.
To assure that the type of scenario performed on one crew would not bias the performance of a subsequent crew, the operating crews also signed statements that during the NRC assessment period, they would not divulge the contents of the scenarios to personnel who had not observed the specific scenario.
Acceptance criteria were developed based on the current operator licensing examiner standards to further assure that the operator weaknesses previously identified had been corrected.
Acceptance criteria were specifically developed for the Station Shift Supervisor (SSS), Assistant Station Shift Supervisor (ASSS)
and for the overall crew which include the SSS and ASSS as well as the other members of the crew.
The criteria used are shown in Attachment Each crew participated in two scenarios.
A crew consisted of the following:
1 - Station Shift Supervisor (SSS)
Senior Reactor Operator (SRO)
1 - Assistant Station Shift Supervisor (ASSS)
SRO 1 - Chief Shift Operator (CSO) - Reactor Operator (RO)
2 - Nuclear Auxiliary Operator E (NAOE) -
RO 2 - Auxiliary Operators - Non licensed Following each scenario the NRC observed the crew self critique of their performance and then held additional discussion to clarify NRC observations during the scenarios.
3.0 SUMMARY OF RESULTS The following table'summarizes the results of the NRC assessments of the Nine Mile Point Unit-1 Operator performance.
The details to support the table can be found in subsequent sections.
In addition, one CSO, of a crew that was rated as satisfactory, did not demonstrate satisfactory performance.
Satis-factory performance was determined by use of the acceptance criteria of Attach-ment 1.
TOTAL NO.
ASSESSED PERFORMANCE DEMONSTRATED SATISFACTORY PERFORMANCE DID NOT DEMONSTRATE A SATISFACTORY LEVEL OF PERFORMANCE STATION SHIFT SUPERVISOR ASSISTANT STATION SHIFT SUPERVISOR CREW
" SSS and ASSS, that are part of.crew that did not demonstrate satisfactory performance, demonstrated individual weaknesses that are considered as part of the crew evaluations 4.0 CONCLUSIONS STRENGTHS AND WEAKNESSES The following section discusses the conclusions, strengths and weaknesses observed during the course of the NRC assessment.
These strengths and weaknesses were generally observed across all operating crews.
Some of the weaknesses noted below are similar to those identified in Inspection Report 50-220/88-22.
While weaknesses in operator performance remain, substantial improvement was noted over previous performance in these area Communication practices for all crews require improvement, some more than others.
Use of slang terminology, imprecise communications and inconsistent repeatbacks or acknowledgements were widespread.
Plant status, changed condition or parameter updates were inconsistently provided or requested by the crews and often not heard or acknow-ledged by the crew members.
The effectiveness of the SSS briefings were inconsistent among the crews.
The difficulties observed during the scenarios were in several instances a result of the poor communi-cation practices.
The poor communication practices did not appear. to be the result of lack of expectations on the part of the operators because all crews did perform some proper communications.
However when the situations posed during the scenario became more challeng-ing, poor communication methods became more apparent.
Operations Department Instruction N1-0DI-1.06 Operational Voice Communications Guide prescribes the communication practices expected of the opera-tions staff, but the prescribed practices were consistently not followed during the scenarios.
As a subset of communication difficulties, several chief shift opera-tors did slot inform the senior reactor operators of recovery actions that they were pursuing unti 1 the recovery actions were completed.
This lack of communication did not allow the SSS the opportunity to properly manage and prioritize the crew member activities and in some cases caused delays in executing or non-adherence to SSS directions.
Communications by all shifts were considered weak.
The SSS and the ASSS generally worked effectively together to respond to the scenarios.
The role of the ASSS varied from crew to crew.
Some ASSSs were very knowledgeable of EOPs and the SSS utilized the ASSS to check his work.. Other ASSSs were used to follow the Primary Containment Control EOP (EOP-4),
and performed Emergency Action Procedures and Emergency Plan Implementation Procedures recommend-ations.
By plant procedures during an emergency the ASSS reverts to a Shift Technical Advisor function and provides little direction to the reactor operators.
The ASSS generally only recommends directions and/or decisions to the SSS.
The SSS makes the final decision or issues the orders.
However, using the ASSS to focus on containment control takes the ASSS away from performing the STA function.
The roles of the reactor operators varied from crew to crew and this affected crew performance on each scenario.
The CSOs were not effective members of the crews when the SSS allowed the CSO to esta-blish priorities and assignments or when the SSS only used the CSO to oversee the two other reactor operators with infrequent control board manipulations required of the CSO.
The use of the CSO, as described above, resulted in certain SRO responsibilities being distributed to the reactor operators.
In addition, no standard approach among thy crews existed for reactor
operator assignments during scenarios.
Some crews assigned the reactor operators to specific panel responsibilities for most of the scenario such as ECCS, feedwater and electrical whereas other crews required the reactor operators to go from panel to panel within each scenario causing them to refami liarize themselves with panel condi-tions before operating the controls.
The lack of definition of the CSO and other reactor operators'oles is considered as a weakness.
4.
The reactor operators were inconsistent in using procedures during electrical switching operations.
Some operators utilized the avail-able procedures and some did not.
Some operators did not utilize the procedures properly.
Difficultywas observed among several crews in the ability to restore 115 kv power when it was made available during the scenarios.
The operator reliance on memory and the inability to restore electrical power to service is considered a weakness.
5.
Assessment of plant impac. when a "power board" (electrical distri-bution bus)
was de-energized was considered a weakness among several crews.
The crews recognized that a power board was de-energized but did not always assess what operating and standby equipment was affected due to power board de-energization.
6..
Several crews did not use all the information available to diagnose failures, especially backup information when primary information was confusing or misleading.
7..
There was an inconsistent approach to avoiding the restricted region of the reactor power to core flow map, The restricted region is that region that has the potential for inducing power oscillations.
Some crews avoided the region; some SSSs told the reactor operators to avoid entering the region, but the operators entered the region, and some crews entered the region with no apparent direction to avoid the region.
Inconsistent avoidance of the restricted region is consi-dered a weakness.
8.
Differences were noted in the crew responses and approaches to beginning a normal cooldown versus stabilizing at rated conditions.
EOP-2 requires that a normal cooldown be initiated.
The EOP basis documents indicate that when all control rods are inserted and the emergency still exists a normal cooldown is required.
Some SSSs stabilized and maintained pressurized conditions rather than beginn-ing a normal cooldown.
Inconsistent application of EOP cooldown steps is considered a weakness.
9.
Several crews closed the MSIVs when all feedwater was lost.
When requested for the procedural basis for the actions, the response provided was that training provided such guidance.
Further investi-gation indicated that a procedure once existed for loss of feedwater
that required such actions, but the procedure does not exist at this time.
The licensee committed to evaluate the appropriate operator actions for a loss of feedwater.
Operator action to close MSIVs when all feedwater is lost without appropriate procedural guidance is considered a weakness.
10.
The SSSs were not consistent in the use of the cautions and notes of EOP-1.
Some incorporated the EOP-1 cautions and notes in the direct-ions provided and some did not until prompted by individual crew members.
11.
Emergency classifications were generally promptly made and imple-mented.
However, recommendations for protective actions for a General Emergency per the guidance of EPP-26 for the same scenario were not always consistent.
Two SSSs recommended evacuation directly per the flow chart in EPP-26 whereas the other two utilized other information received on radioactive releases and did not recommend protective actions be taken.
12.
No procedure or policy direction is available to reactor operators for actions following a loss of plant annunciators.
This is consi-dered a weakness.
13,All SSSs and ASSSs entered the EOPs when the entry conditions were satisfied.
14.
Placekeeping techniques in the EOPs varied among the SSS and ASSS.
Some individuals used a line out method to determine steps accom-plished and circled the place of the EOP flow charts when they were in a holding or waiting condition.
Others simply checked off the steps completed.
Lack of consistency could cause problems when crew members work with different shifts or if a shift turnover occurred during the emergency.
All SSSs and ASSSs were observed to consis-tently update the EOP flow charts when parameter data was received by crossing out the old data.
5.0 ASSESSMENT BY SHIFT CREW Crew A - Station Shift Su ervisor Holthouse Crew knowledge and use of EOPs was satisfactory; however, during the scenario with partial rod insertion, the SSS did not enter EOP step 4.5.2 to control water level above Top of Active Fuel (TAF) after emergency depressurization, but restored water level to the normal band.
Appropriate Emergency classifi-cations were performed.
The SSS incorporated EOP-1 cautions and notes when providing direction to the crew.
Communications with the crew were not always consistent with the facility requirements and were imprecise and several times utilized slang type terminology.
~ I
Crew B - Station Shift Su ervisor Shellin The SRO use of EOPs was weak.
The SSS exited EOP-2 prematurely in both scen-arios and missed steps in the EOPs in both scenarios.
In one scenario the SSS did not direct tripping of drywell cooling fans before spraying containment and was slow in beginning a normal cooldown after a scram with all rods inserted.
In the second scenario, the SSS entered EOP-8 after water level had dropped to below TAF and ordered core spray pumps to be locked out due to taking the wrong path through EOP-8.
This action resulted in conditions which could not assure adequate core cooling, and this situation was eventually recognized by the SSS.
The SSS did not take action to vent containment for hydrogen control per EOP-4, but continuously monitored the parameter for changes.
Communications between the SSS and crew were not precise, and they consistently used slang terminology, Poor communication occurred from the crew to the SSS and from the SSS to the crew.
Very few crew updates were provided; and, on several occasions, the crew requested that the SSS provide his plans regarding the EOP's.
The SSS also allowed imprecise communications to occur among other crew members.
Ouring the second scenario the SSS used good diagnostic approaches to confirm that the RPS had not failed but that the annunciator system had failed.
Appropriate emergency classifications were made.
The CSO (a reactor operator)
was not effectively utilized by the SSS.
The CSO performed minimal control board operations because he acted as a supervisor for the other two reactor operators on shift.
As a result, these two reactor operators were overloaded with control board manipulations.
The CSO was familiar with EOP entry conditions and effectively prompted the SSS on the entry conditions.
However, the CSO (who was not reading the EOP's since the SSS does this) prompted the SSS on several occasions to secure equipment being utilized in accordance with the EOP's.
On these occasions, the SSS would initially concur with the CSO, then rescind his concurrence after discussing these actions with the ASSS.
The result of these activities was added confu-sion among the crew members as to expected actions and instances where needed equipment was nearly prematurely secured.
This crew also demonstrated a lack of teamwork which resulted in a poor coordi-nation of activities.
The reactor operators were observed to have a verbal confrontation on individual duties and responsibilities.
The confrontation was possibly caused
.by a lack of definition in th'e individual duties and responsi-bilities.
The SSS appeared to lack confidence in the ASSS.
The ASSS displayed a lack of assertiveness in a few instances; however, recommendations made to the SSS were generally good.
Several difficulties were experienced by the operators on the control boards in electrical power operation, which complicated the scenario, and in the restoration of feedwater, Overall, this crew was considered unsatisfactor Crew C Station Shift Su ervisor - Earls Knowledge and use of EOPs was satisfactory.
However, during emergency depress-urization, the SSS did not monitor reactor pressure, but kept requesting inform-ation on reactor level and, as such, was slow in responding to step 2.5 of EOP-8 which prescribed when depressurization was to be stopped.
Appropriate emergency classifications were performed.
The SSS kept the crew constantly informed of plant status and his plans with respect to the EOPs.
Communication was weak during the emergency depressurization portion of one scenario.
Crew 0 Station Shift Su ervisor - Stancliffe Knowledge and use of EOPs were satisfactory.
Emergency classifications were appropriate in one scenario and conservative in the other scenario.
The SSS declared a general emergency without all of the conditions required to make such a classification in one scenario.
The SSS did not diagnose that the leak entering the reactor building was coming from the scram discharge instrument volume but followed the EOP action that would be required if there was a
challenge to secondary containment so diagnosis was not required to handle the scenario.
Severa'.
instances of poor communications were observed at all levels.
The CSO for this crew was not effectively integrated into the crew.
Several instances of weaknesses were observed which are described in section 6.
Crew E - Station Shift Su ervisor - Parish Knowledge and use of EOPs was satisfactory.
Emergency classifications were appropriate.
Overall crew communication was minimally acceptable and in a few instances crew communications were not adequate to inform the SSS of plant status changes to allow the SSS to direct activities.
The SSS was not informed that the operating liquid poison pump had tripped for several minutes (this delay was also the result of weak assessment of the effects of a power board de-energization)
and, that the leak in secondary containment had stopped when the scram had reset and that power was able to be restored to the power board that had lost power.
Crew R - Station Shift Su ervisor - Li11 Knowledge and use of EOPs were satisfactory.
Emergency classifications were appropriate, but the upgrade to a Site Area Emergency when all annunciators were lost and a transient occurred was somewhat late.
The SSS did not diag-nose, and the remainder of the crew did not effectively assist in the diagnosis of the loss of annunciators, and he believed that he had a failure of RPS, even though the RPS functions were consistent with a single failed APRM and tests of the annunciators proved they were not functioning.
Oirecting a manual scram with no annunciator s available was not necessary.
Communication was generally satisfactory in the first scenario with more imprecise communication observed during the second scenario when annunciators were lost.
~ ~
6. 0 INDIVIDUAL WEAKNESS CSO of Crew D
The CSO demonstrated significant weakness in communications in that he failed to acknowledge significant information and instructions relayed to him or failed to repeat back information and instructions on numerous occasions.
The CSO did report some actions such as performance of immediate scram actions; but, on several occasions, he did not assure his information was received (i.e. reports to others made while their back was turned or they were speaking to someone else).
Several times the CSO silenced annunciators without report-ing the alarm.
The CSO appeared to have a weak understanding of plant conditions, as evidenced by his unneeded action to close a turbine bypass valve (previously manually opened)
in order to reduce flow after an emergency blowdown commenced and the MSIV's were closed.
The CSO also dispatched a fire brigade to '.nvestigate a fire alarm in the reactor building after the reactor building had been evacuated and a General Emergency had been declared.
This action placed, the fire brigade at risk of excessive radiation exposure without the cognizance of the SSS.
In summa, the CSO's weak communications, apparent lack of understanding of plant status, and independent actions resulted in ineffective integration with the shift crew.
7.0 EOP-4 De ressurization Strate During observation of simulator training (as reported in Inspection Report 50-220/89-11),
the inspector questioned the implementation of a step in EOP-4, Primary Containment Control, regarding emergency depressurization.
The use of the main condenser when emergency depressurization is anticipated versus when emergency depressurization is required was discussed.
The inspector reviewed licensee procedure bases and other documentation and the EOP Generic Technical Guidelines.
The inspector also discussed this concern with licensee training and technical staff members and operations management.
The inspector noted a
different approach depending on which party was addressing the issue and requested that a clear policy be provided before evaluations were conducted.
This policy was provided as requested and evaluations were performed as sche-duled.
No concerns were identified regarding the emergency depressurization policy.
.0
~Ei M
An exit meeting was conducted on May 25, 1989, at the simulator facility with the licensee senior site representatives (denoted in paragraph 1.0).
The inspection scope and preliminary findings were summarized at the meeting.
The senior licensee management representative questioned whether the NRC observed any operator attitude difficulties with training.
The NRC did not observe any such problems during the course of the operator assessment A subsequent telephone exit was conducted on June 1,
1989 with the licensee representatives denoted in paragraph 1.0 to provide the licensee with addi-tional conclusions as detailed in the inspection report.
The NRC inspectors indicated that a licensee response would be requested to address the weaknesses identified, as well as remedial training for the individual and crew that was not satisfactory.
Additional NRC staff reassessment would be required for the crew and individual prior to startup and that NRC staff may also assess one additional crew(s) to assess the adequacy of the licensee actions regarding the weaknesses identifie ATTACHHENT 1 Acce tance Criteria
Ui'4KRSTPM)I%3/IiMTERi"RETATICNCF ANhLRCIATCR/PLAFul SlC+A S Did the STATICN HIFT SLFERVIBCR:
(a) M3TICE and ATTEND to annunciator/alarm signals in order of their importance/severity?
Accurately and efficiently, in all instances.
Ninor difficulties in attending to or prioritizing attention Failed to attend to/priori ti "e Lmpol tant alai ms'ic%4 response and/ot distracted by nuisance alarms.
I (b) Correctly INTERPRET the meaning and significance of alarms and annunciators?
Understood/quick 1y determined what failures alarm-were indicating Ninor inaccuracies/~~a delays in alarm interpretation.
Nisinterpretations, delays or misuse of PFCs rem<lted in plant degradatxm.
(c) VERIFY that annunciator/alarm signals were consistent with plant/systan conditions?
Enmre proper verification when
-., necessary.
Ninor lap~~ in alarm verification. but no inappropriate actions as a result of 3.nadequate verificaticn.
Failed to verify and or improperly verified cn important occasions:
didn'0 notice inconsistency between alarms and plant conditions.
Satisf ac tory m.EMTS:
LAsatisfactory
DIACNCSIS CF EVENTS/CCNDITIOW PA ED QN SIC+A S/FEADINSS Did th STATION WIFT SLFERVIR'R:
(a)
RECOGNIZE offwormal trends/status?
Ctuick 8nd accLll ate recognition.
~~1A= delays in rccogni "ing offwormal conditions.
Spurious omissions.
delays of inaccLll acies in recogniticn.
(b) Ensure the collection of CX~=T. ACCURATE and CCPF~ information and reference material upon which to base diagnoses?
EnsLlre that all relevant 3.nd.Lcat3.ons 8nd ImferenCeS Were checked.
Minor instances of over looking, overreliance on misinterpretation of indicaticns and or I eferences 3.
Seric ls instances o
failul"e to Llse ol" heed important informaticn or misuse of data.
(c) Correctly DIAEN3SE plant, conditions based on control room indications?
Diagno~ were accLli ate Minor errors/
difficulties in diagnosis Faul ty diagnosis adversely impacted pl8n't statLIs.
, Satisf ac tory 01sa tisf ac tory CO I'ENTS:
UNIXISTAWIN3 CF F~/SYSTEM FEB G~
Did the STATICN &DRIFT B F~IR38:
(a)
INTERFFET ccntrol room information correctly and efficiently to ascertain and verify the status/operation of plant systems'
Accurate and efficient informaticn interpretation.
Ninor errors in interpreting information.
Serious omissions, delays or 1naccul acle5 1n information interpretation.
(b) R~~in ATTENTIVF to control rccm indicaticns'?
Regularly scanned indicaticas; anticipated el~ages in plant conditions due to events in p'iigress a
Sporadic scanning of indications; minor lap~
1n anticipating predictable changes Rarely scanned 3.nd3.catLcns
~ fa1 led to anticipate predic "able change" in plant. status.
(c) Demonstrate through diwctives and actions a thorough NDCRSTP%M of
~ the FU-'Ãf. SYSTENS.
and ~~&PS operate and interact?
Demcnstrated through
.:, understanding of hex@
systems/components operate and interact.
Ninor instances of errors due to gaps in kncmledge of how systems/compcnents operate.
inadequate knowledge of system/compcnent operation resulted in serious mistakes of plant dcgradaticn.
Satisf ac tory 03'RENTS:
Unsat15 lac tory
CO. ( I@ACE/LEE CF FRGCEDLRES Did the STATICN MIFT KX-ERVIHK:
(a)
REF&< to correct procedures and procedural steps when appropriate?
Requested/readily located ai 1 appropriate procedures as nEcessary Minor lapses in referring to/
locating appropriate procedures s
Failed to,correctly refer to prccedures in important instances.
(b) lEED PRKEDlRES CGMCTLY. including following procedural steps in correct ~uence, abiding by procedural cautions and limitations, selecting correct paths on decision blocl.s and correctly transitioning bet PPil pl ocedul es?
Ensured accurate, timely enactment of pl cY edul al steps
~
Minor errors, but made nEcessary corrections in timely fashion.
Significant errors which led to impeded/
slow recovery and/or l.lnnecessary plant degradaticn.
(c) Ensure the safe efficient II1=iEI'ENTATIGNof procedures by the CF&P.
Assess Shift Supervisor
'directions provided to the crew for acceptability. If directions al"e given to crewinform SS.
Allowed lapses in implementation by the crew.
Read procedures to himself; failed to orchestrate/veri fy use of procedures by crew members.
Satisfactory Lhsatisf ac tory CXN"FNTS:
CQvPVUICATIMS /~ INTERA"TIGYS Did the STA IQA DRIFT ~~PHYSI~~
(a)
Cemrr nicate in a clear, easily understood mann r'?
Canna.mications were tim ly. clear-cut.
and easy o hear and understand.
At, times ccxwxmications were ccnfusing.
hard to hear or understand.
Crt.nicaticns were ill-timed. vague and/or difficult to hear of interpret.
(b) Keep crew @embers and those a outside the ccntml room informed of plant status'?
Provided othef ~ with accurate, pertinent information thrcughout scenario.
Ninor instances of needing to tx prompted for info; scxne incomplete inaccurate info.
Failed to provide needed information.
(c) EbELFES FECEIPT of clear easily understood cmmnications from the crew and others?
Requests informaticn clarification when necessary
$
understands CGANTdAicat1ons from others.
Ninor instances of failing to require or acknowledge info'rom others.
Failed to request needed info or inattentive when info was provided, serious mia.understanding among the crew.
Satisfactory Lhsatis factory CPtHC S:
DIRECT RIFT CFERATICNS Did the STATIC RIFT SLFERVIKR:
(a) Take TIMELY, DECISIVE ACTICN w~ problems arose?
Took early remedial recuperative action when necessary s
Minor instances of failing to take action within reasonable period of time, Failure to take timely action resulted in deterioration of plant conditions.
(b) Provide TI~Y, hELL M3 "l-fi OUT DIRECI IV&that facilitated crew performance and demonstrated appropriate concern for the safety of the plant. staff, and public?
Directives Enabled safe, integrated cI"Ew pel formancea Minor instances of incorrect. trivial or difficult to carry out ol derse Directives inhibited safe crew performance:
crew had to explain why orders couldn't or sh~lldn't be follmM.
(c) Stay in a position of OVERSITE providing an appropriate aIlxx.lnt of Direction and Guidance?
Stayed involved, but.
. withrlt being too intrusive; anticipated crew needs and provided guidance wh:-n necessary.
Crew had to solicit a5515tance on cccasicn, interfering with their ability to carry cut acticns.
Lost tM big picture.crau had to repeatedly request/
pl"ov1de guidance failed to verify correct Enactment of directives.
(d) KLICIT and INWRF RATE FEEDBACK from crew to foster an effective, team orientated approach to problem solving/decision making?
Involved crew in problem solving procc&s as appropriate, leading to effective team decisicn making.
At times, failed to involve crew in decisicn making when it would have been appropriate, detracting from team orientated approach.
Decisions made witht-It needed crew par ticipaticn or consul tati~; crew d1v151vEfle55 was col Inter produc tiv LNDERSTPhBIhG/INTERF~ATIGV CF Pb"4PCIATCR/ALAMOSI~
Did the AGISTER,VT STATIOV RIFT SLFERVISCR:
(a) 83TICE and ATTEND to annunciator/alarm signals in order of their importance/severity?
Accurately and efficiently, in all instances.
Minor difficulties in attending to or prioriti=ing at tention Failed to attend to/pl iol itize important alarms; slow response and/or distracted by nuisance alarms.---
(b) Correctly INTER'~ the meaning and significance of alarms and annunciators?
Understood/quickly determined what failures alanna were indicating Minor inaccuracies/acme delays in alarm interpretaticn.
l1isinterpretations, delays or misuse of Cps resulted in plant degl adat3.on
~
(c) VERIFY that annunciator/alarm signals were ccnsistent with plant/system conditions?
E'nsure proper verification w"an
" necessary.
I1inor lapses in alarm verification, but no inappropriate acticns as a result of inadequate verification.
Failed to verify and or improperly veYified cn important occasions; didn'
notice inconsistency between alai ms and plant conditions.
Satisf ac tory CCPI"ENIS:
Lhsatisf ac tory
DIA343$IS M EVENS/CCNDITICINS BASED CN SIGNALS/~~IACG Did the ASSISTPblT STATICN DRIFT RX-~ISGR:
(a)
RECCGNIZE offwormal trends/status?
Quick and accurate recogniticn.
Some delays in recognizing off~ormal conditions.
Sp Irious omissions, delays of inaccLII"acies 1.n recogniti~.
(b) E'nsure the collecticn of CCI~,
ACCURATE and CCPF~ information an@-.-
reference material upcn which to base diagnoses?
Ensure that all relevant indications and references were checked.
Ninor instances of overlooking.
overreliance on misinterpretation of indications and or references
~
Serious instances of failLlre to u50 ol heed important information ol misuse of data r (c) Correctly DIAENGK plant conditions based on ccntrol room indications?
Diagno~ were accul ate e
Minor errors/
difficulties in dlagnosls Faul ty diagnosis adversely impac wd plant statLIsa
,'" Satisfactory CCN"ENTS:
Lhsatis factory
UNDERSTANDING CF F~/SYSTEN REFORGE Did the AMISTPNT'TATIONB"IFT ~~MVISK:
(a)
INTERPRET control room indicators correctly and efficiently to ascertain and verify the status/aperaticn af plant systems?
Accurate and efficient instrI.Iment and display interpretaticn.
Ninor errors in interpreting instrl.lments and displayss Serious omissions, dBlays of inaccuracies in inst rl.lmcnt and display interpretation. "--
(b) Remain ATHBtTIVE to central roam indications?
Regularly scanned indicaticns:
c~1ticipated changes in plant conditions due to events in pr~ress.
I Sporadic ~arming af 3.nd3.cat3.cns j l113.nol lapses in anticipating predictable changes.
Rarely scanned indications",failed to anticipate predictable ch ages in plant status.
(c) Demcnstrate through directives and actions a thorough LNDERSTPblDIh6 of how the F:A4T, SYSTENS, and CO'PV&!TS operate and interact?
Demcnstratcd through
' understanding af how systems/components operate and interact..
I'iinar instances af errors due'o gaps in knowledge of how systems/ccxnpcnents operat.e.
Inadequate knowledge af system/compcnent operation resul ted in SBI ious mistakes of plant degl adaticn
~
Satisf ac tory Lhsatisfac tory CXN"ENTS
IXN=t IPME/LEE CF FRCCEDLMS Did the ASSISTANT STATICS MIFT KPERVISCR:
(a)
REFER to correct procedures and procedural steps when appropriate?
Requested/readily located all appropriate pl"ocedures as necessBry a
Ninor lapses in referring to/
locating appropriate procedures.
Failed to correctly refer to procedures in important, instances.
(b)
USED FROCEXXRES ~CTLY, including following procedural steps in correct sequence, abiding by procedural cauticns and limitations, selecting correct, paths on decision blocks and correctly transitioning between prccedures?
EnsurEd accul ate timely Enactment of prOcedural stepsa Ninor errors, but made nEcessBry corrections in timely fashion.
Significant. errors which led to impeded/
slow recovery and/or unnecessary plant degradaticn.
(c) Ensure the safe efficient IIW~NTATIOMof procedures by th CFEAR?
Vmpt RK and crew infol med of
" procedural status; got acknowledgement from crew when reading procedures.
I t
SSS occasional ly had to question ASSS regarding status:
allowed lap~~ in implementation by the crew.
Read procedures to himself; failed to orchestrate/veri fy use of procedures by crew AK%berse Satisfactory CO"VM'S Pnsatisf actory
Did the ASSISTANT STATICN RIFT R~ERVIKR:
(a) Ccxrnwicate in a clear, easily llnderstaad manner?
Canmicaticns were timely, cleanout.
and easy to hear and understand.
At times comm.lnicatians were confusing, hard to hear ar llnderstand.
Ccmnx lnicatians were ill timed vague and/ar difficult to hear of interpret.
(b) Keep crew members and those outside the cantral racm informed of plant."-"
status?
Provided others with accurate, pertinent information throughout scenario.
Minor instances of needing ta be prompted far info:
incomplete inaccurate infa.
Failed to provide needed infornlatian.
(c) BC3JFKS RECEIPT of clear easily understood commlnicaticns fran the crew and others?
Requests infarmaticn clarification when necessary e
Undel stands
'amfBJnicatians from others.
Minor instances of failing to require or ackncwledge info free ath rs.
FailEd ta request needed info al inattentive wI-en info was provided", serious misunderstanding among the crew.
Satis'factory CXNWAS Lhsatisfac tory
DIRECT SHIFT CFERATICOS Did the ASSISTANT STATICN SHIFT RFERVIKR:
(a) Take TI~Y. DECISIVE ACTION when problems aro~?
Took early remedial recuperative ac:ticn when necessary.
Ninor instances of failing to take action within reasonable period of time, Failure to take timely action resul ted in deterioration of plant conditions.
(b) Provide TI~Y, PELL THOJSHT CUT REC3'$"EhKATICNS iR DIRECTIChS that.
facilitated crew performance and demonstrated appropriate concern far the safety af the plant, staff, and public?
Reccmmdatians al d3. ectives enabled safe, integrated crew performance.
Ninor inst.ances of incorrect, trivial or difficult. to carry out acions.
Reccgmendations and directions inhibited performance:
crew had to e':plain why action couldn'0 or shouldn'
be followed.
(c) Stay in a position of CLTXiSITE providing an appropriate amcxint af Dz.rect3.cn and SLQ dance?
Stayed involved, but
"without being toa intriisive; anticipated crew needs and provided guidahce when necessary.
Crew had to solicit assistance cn occasion, interfering with their ability ta carry aut actianse Lo t the big picture:
SSS had to repeatedly request assistance; failed to verify correct enactment of SSS directives.
(d) SG ICIT and IMXX~TEFEEDBACK frcxn crew to faster team orientated approach to prablem salving/decision
an effeet.ive.
making?
Involved crew in problem solving prccess as appropriate, leading ta effective team decision making.
At times, failed ta invalve crew in decisicn making when it would have been appropriate, detracting fram team orientated approach.
Decisions made without needed crew participaticn or consultation:
crcm divisiveness was ccx.inter-productiv UNDERSTANDING/INTERPRETATION OF ANNUNCIATOR/ALARMSIGNALS DID THE CREW:
(a)
NOTICE and ACKNOWLEDGE alarms; and ATTEND TO'alarms in order of their importance/severity?
All alarms that directly related to significant changes in plant conditions were noted Minor awareness or response difficulties or lapses Failed to notice and/or extremely slow at responding to significant alarms at critical times; easily distracted by nuisance alarms (b)
Correctly INTERPRET the meaning and significance of alarms and annunciators (including the use of the Alarm Response Procedures, as applicable)?
Crew readily'determined Minor. inaccuracies in what failures/events-
'larm interpretation alarms were indicating but without safety related consequences (c)
VERIFY that annunciators/alarm signals were consistent conditions?
Significant misin-terpretations, resulting in plant degradation with plant/system All necessary verifi-cations performed, including the identi-fication of erroneous Verification of failed systems was poor or altogether absent Minor lapes in alarm verification, but no inappropri'ate actions taken as a result of inadequate verification alarms SCORE ON UNDERSTANDING/INTERPRETATION OF ANNUNCIATORS/ALARM SIGNALS:
Satisfactory Unsatisfactory Comments:
DIAGNOSIS OF EVENTS/CONDITIONS BASED ON SIGNALS/READINGS DID THE CRBl:
(a)
RECOGNIZE off-normal trends/status?
Timely and accurate recognition of trends even prior to alarms Recognition of trends
.at time of, but not prior to, sounding of alarms Failed to recognize trends, even after sounding of alarms and annunciators (b)
USE INFORMATION and use REFERENCE MATERIAL (prints, books, charts) to aid in the diagnos'is/classification of events and conditions?
2
Correct, timely use of information and reference material led to accurate diagnoses Minor errors by crew in use or interpretation of information and reference material Failure to use reference material, misuse/misinterpretation of information resulted in improper diagnoses (c)
Cbrrectly DIAGNOSE plant conditions based on those control room indications?
Diagnoses by crew were accurate and timely Minor errors/diffi-culties in diagnoses Faulty diagnoses resulted in incorrect control manipulations SCORE ON DIAGNOSIS OF EVENTS/CONDITIONS BASED ON SIGNALS/READINGS.
Sati s factory Unsati s factory Comments:.
UNDERSTANDING OF PLANT/SYSTEMS RESPONSE DID THE CREW:
~
~
(a)
LOCATE and INTERPRET control room indicators correctly and efficiently to ascertain and verify the status/operation of plant systems?
Accurate and efficient instrument location
interpretation by all crew members Minor errors in locating or interpreting instruments and displays; some crew members required assistance Serious omissions delays or inaccuracies made in instrument interpretation (b)
Demonstrate an UNDERSTANDING of how the plant, systems, and components operate, including setpoints, interlocks, and automatic actions.
All crew members demon-strated thorough understanding of how systems/components operate Minor instances of errors due to gaps in crew knowledge of system/
component operation; some crew members required assistance Inadequate'nowledge of system/component operation resulted. in serious mistakes or plant degradations (c)
Demonstrate an understanding of how their ACTIONS (or inaction) affected system/plant conditions?
2
All members understood the effect that actions or directives had on plant/system conditions Actions or directives indicated minor
,
inaccuracies in under-.
standing by individuals, but actions were corrected by'eam SCORES ON UNDERSTANDING OF PLANT/SYSTEM RESPONSE:
Crew appeared to act, without knowledge of or disregard to, effect on plant Satisfactory Comment:
Unsatisfactory
COMPLIANCE/USE OF PROCEDURES DID THE CREW:
(a)
REFER TO the appropriate procedures in a timely manner?
Failed to correctly refer to procedures when required, resulting in faulty system operation Crew used procedures Minor failures by as required; knew crew to refer to what conditions were procedur es without, covered by procedures prompting, but did and where to find.them affect plant status
. (b)
CORRECTLY, IMPLEMENT procedures, including. following procedural steps in correct sequence, abiding by cautions and limitations, selecting correct paths on decision blocks',
and correctly transitioning between procedures.
Timely, accurate Minor instances of Importance procedural enactment of procedural misapplication, but steps were not enacted steps by crew, corrections made in correctly, which led demonstrating thorough sufficient time to to impeded and/or slow.
understanding of avoid adverse impact recovery or unnecessary procedural purposes/bases degradation (c)
RECOGNIZE. EOP ENTRY CONDITIONS and carry out appropriate immediate actions without the aid of references or other forms of assistance?
Consistently accurate and timely recognition and implementation Minor laps'es or errors; individual crew members needed assistance from others to implement procedures Failed to accurately recognize conditions or execute actions, even with use of acids SCORE ON COMPLIANCE/USE OF PROCEDURES AND TECHNICAL SPECIFICATIONS:
Satisfactory Unsatisfactory Comments:
CONTROL BOARD OPERATIONS DID THE CREW:
(a)
LOCATE CONTROLS efficiently and accurately?
Controls and indicators were located without hesitation by individual operators Instances of
.hesitancy/
difficulty in locating controls by one or more operators Instances of failure to locate controls jeopardized system status (b)
MANIPULATE.CONTROLS in an accurate and timely manner?
a Smooth manipulation of the plant within controlled parameters Minor shortcomings in manipulations, but recovery from errors without causing. problems Mistakes made in manipulating controls caused system transients and related problems (c)
Take MANUAL CONTROL of automatic functions, when
- 3
appropriate?
All operators took control, and smoothly operatored automatic systems manually, without assistance, thereby averting adverse events minor delays and/or prompting necessary before overriding/
operating automatic functions, but plant transients were avoided when possible.
Failed to control automatic systems manually, even when ample time and indications existed SCORE ON CONTROL BOARD OPERATIONS:
Satisfactory Unsatisfactory Comments:
V COMMUNICATIONS/CREW INTERACTIONS DID THE CREW:
(a)
EXCHANGE complete and relevant information in a clear, accurate, and attentive manner?
Members informed each other of relevant info.
and actively sought and listened to info. from others as/when necessary Communications generally complete and accurate, but some instances of needing to be prompted, or failing to acknowledge or respond to info. from others Members did not inform each other of abnormal indica-tions or when performing evolutions; inattentive when important info. was requested or provided (b)
INTERACT with other regarding issues/circumstances outside of,their individual area of responsibility to facilitate safe plant conditions?
Members assumed responsibility for issues outside their own boards, as appropriate Members listened to each others conversations in general; major technical errors corrected Members were
~ inattentive to what was happening around them; poor coordination of activities (c)
MAKE TEAM DECISIONS in a'imely, effective manner?
Al 1 individuals'rovided input to decisions.
Decisions resulted in early, recuperative action Major team decisions generally included input from most crew members, but some
.delays or other problems in reaching effect'ive decisions Leader or other crew members did not accept input from others, resulting in incorrect or untimely decisions/
directives SCORE ON COMMUNICATIONS/CREW INTERACTIONS:
V Satisfactory Unsatisfactory Comments: