IR 05000220/1989024
| ML17056A458 | |
| Person / Time | |
|---|---|
| Site: | Nine Mile Point  |
| Issue date: | 11/14/1989 |
| From: | Conte R, Walker T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17056A457 | List: |
| References | |
| 50-220-89-24, NUDOCS 8911290058 | |
| Download: ML17056A458 (56) | |
Text
U.S.
NUCLEAR REGULATORY COMMISSION
REGION I
'I I
Report No.
50-220/89-24 Docket No.
50-220 License No.
DPR-63 Licensee:
Niagara Mohawk Power Corporation 301 Plainfield Road Syracuse, New York 13212 Facility Name:
Nine Mile Point, Unit
Inspection at:
Scriba, New York Inspection conducted:
September 26 - 29, 1989 Inspectors:
N. Conicella, Operations Engineer R.
Temps, Resident Inspector
+i p-r. Mc.rA c>>
T. Walker, Senior Operations Engineer rr/r~r/~~
Date Approved by
~p R. Conte, Chief, BWR Section, Operations Branch, DRS
//- i'/-8'ate 85'i 12900 ~8 85'l,i 22 PDR ADOCK 050002.0
'
PD:
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 (EOPs),
during emergency situations and transients.
The performance of two on-shift operating crews was evaluated using NRC developed scenarios on the Nine Mile Point Unit 1 plant specific simulator.
No violations or deviations were identified, Operator performance in the areas of crew communications and definition of duties, assignments, and responsibi-lities was improved compared to performance during a previous NRC inspection in
,this area.
Both of the crews that were evaluated were determined to be satis-factory.
One Station Shift Supervisors (SSS)
and one Assistant Station Shift Supervisor (ASSS) did not demonstrate satisfactory performance in the use of EOPs.
The same ASSS was also unsatisfactory in performing the duties of the Shift Techni-cal Advisor (STA).
All other individuals performed satisfactorily, including one individual that had not. demonstrated satisfactory performance in a previous evaluation.
Certain crew weaknesses (discussed in section 2.3.2 of this report) were ob-served that appear to be similar to weaknesses observed during the evaluations in May, 1989.
This indicates that the licensee's cori ective actions in these areas may not have been completely effective.
Five unresolved items related to the maintenance of operator licenses and Emergency Operating Procedures were closed based on the results of this inspec-tion and inspector review of documentation provided to the NRC.
Three un-resolved items related to the maintenance of operator licenses were updated, but not closed pending licensee response to the Notice of Violation issued on September 22, 1989.
The inspection of the implementation of NRC Bulletin 88-07 on power osci llations is documented in section 4 of this report.
No violations were identified.
A few minor discrepancies, mostly clerical in nature, were identified in the procedures that were changed to address power oscillations.
Training on power oscillations was not complete at the time of the inspection.
Observations during the evaluations of operator performance on the simulator indicated that the training provided has been effectiv DETAILS 1.0 Persons Contacted Licensee Representatives L
L. Burkhardt, Executive Vice President Nuclear Operations J.
Wi 1 1 i s, General Superintendent K. Dahlberg, Station Superintendent Unit
R. Randall, Operations Superintendent W.. Bandla, Assistant Superintendent Operations N., Peifer, Manager Nuclear Services A. Rivers, Superintendent Training R. Seifried, Assistant Superintendent Training R. Sanaker, Supervisor Operations Training Unit
S. Burton, Training Instructor I'1. Peterson, Training Instructor M. Colomb, Manager Regu'latory Compliance D. Straka, Regulatory Compliance D. Coleman, Assistant Supervisor Reactor Analyst U.S. Nuclear Regulatory Commission
+ J. Wiggins, Chief, Projects Branch
+ R. Gallo, Chief, Operations Branch, DRS
+ R. Conte, Chief, BWR Section, Operations Branch, DRS Denotes those present for the exit meeting on September 29, 1989.
Denotes those who participated in the telephone conference call on October 4,
1989.
2.0 0 erator Evaluations 2. 1 Overview of Evaluations Inspection Report 50-220l89-13 identified one shift crew and one indivi-dual that did not demonstrate satisfactory performance when operator proficiency and ability to use facility procedures were evaluated during the week of Nay 22, 1989.
Generic (crew) weaknesses were noted during the Nay 1989 evaluations, specifically in the areas of crew communications and definition of duties, assignments, and responsibilities.
The licensee, in a letter dated September 14, 1989, responded to the inspection findings.
The licensee stated that the crew and individuals that did not demonstrate satisfactory performance would be ready for re-evaluation, by the NRC during the week of September 25, 1989.
The NRC conducted the followup assessment of Nine Nile Point Unit 1 opera-tor proficiency and use of facility procedures during the week of Septem-ber 25, 1989.
The NRC developed scenarios to be run on the Nine Nile
Point 1 plant specific simulator to determine if previously identified weaknesses had been corrected.
The NRC verified the adequacy of these scenarios prior to their use with assistance of facility representatives from the training and,operations departments, These individuals also assisted in operating the simulator during the NRC evaluations.
All individuals that had access to the scenarios prior to or during the evalu-ations signed security agreements to ensure there was no compromise of the evaluations.
The acceptance criteria used dur'ing the evaluations were identical to the criteria used during the previous evaluations in May 1989.
Specific ac-ceptance criteria were used for the SSS; the ASSS, and for the crew (including the SSS and ASSS).
The criteria used are included as Attach-ment 1.
Each crew participated in two scenarios.
Following each scenario the NRC observed the crew self critique their performance and then held additional discussion to clarify NRC observations during the scenarios.
2.2 Summar of Evaluation Results The following table summarizes the results of the NRC assessments of Nine Mile Point 1 operator performance.
The details to support the results are discussed in subsequent sections of this report.
Satisfactory performance was determined by use of the acceptance criteria described in Attachment l.
I I
DEMONSTRATED
)DID NOT DEMONSTRATE(
TOTAL NO.
EVALUATED SATISFACTORY PERFORMANCE SATISFACTORY PERFORMANCE I
I STATION SHIFT I
SUPERVISOR I
ASSISTANT I STATION SHIFT SUPERVISOR CREW 2.3 Crew Stren ths and Weaknesses The following section discusses the strengths and weaknesses observed during the NRC evaluations'hese strengths and weaknesses were generally 'observed in both crews.
Some of the weaknesses identified appear to be similar to weaknesses identified in Inspection Report 50-220/89-13 which documents the evaluations administered in May 198 The repeated weaknesses indicate that the licensee's actions to correct the observed weaknesses may not have been completely effective.
2.3.1 Communication practices generally improved compared to the observations from the pi evious evaluation.
There were very few examples of improper communication practices and most of the improper communications that did occur were corrected by other crew members.
Communication practices did not deteriorate as the scenarios became more challenging.
Host of the communications during the scenarios adhered to the practices prescribed in Operations Department Instruction (ODI.).1.06, Operational Voice Communica-tions.
Crew interactions, including definition of crew duties, assignments and responsibilities improved compared to the observations from the previous evaluation.
Both crews used the Chief Shift Operator (CSO) effectively and senior reactor operator (SRO) responsibilities were not performed by reactor operators (ROs).
The role of the ASSS varied between the two crews observed," but this was determined to be an individual weakness of the ASSS who did not satisfactorily perform the STA function.
The ability of the SSSs to effectively command and control activities of the crew during transient and emergency situations was noted as a strength.
All ROs observed appeared to be proficient at control board manipulations.
I
'2.3.2 Crew Weaknesses Neither crew adequately assessed the impact on the plant when a Reactor Protection System (RPS)
bus that supplied power to various instruments and controls was de-energized.
Failure to determine whether instrumentation was accurate or inaccurate resulted in confu'sion among the crew and com-plicated the recovery from the transient.
This weakness was similar to an observation from the previous evaluation that the crews did not always assess what equipment was affected when a power board (electrical distrib-ution-bus)
was de-energized.
It appears that the licensee's corrective actions in this:-area were focused too narrowly to fully correct the defi-ciency.
Procedure revisions and training to correct thi s deficiency did not address all types of electrical distribution busses.
The operators did not always use all available information for diagnosing equipment failures and events.
For example, one crew determined that a
single recirculation pump had tripped when a failure of the master recir-culation flow controller occurred because they looked at only one of the five recirculation pumps.
The other crew did not recognize that a steam leak was occurring in the drywell because they did not )ook at drywell humidity.
The same observation was noted during the Nay 1989 evaluatio According to the licensee, use of all available indications to perform diagnoses has been addressed in training on an on-going basis.
It appears that continued emphasis in this area is needed to'remediate this weakness.
The operators were occasionally slow to recognize changes in plant status, particularly changes in reactor vessel level trends.
This finding was similar to the observation from the May 1989 evaluation that changes in plant status and conditions, and updates on key parameters were inconsis-tently provided or requested by,the crews.
This aspect of the weakness in communications was not addressed in the licensee's response to the observ-ed 'weaknesses.
The corrective action included stressing strict adherence to ODI 1.06, Operational Voice Communications, but this instruction does not address providing or requesting information on plant status.
It appears that the licensee's corrective action in this area did not address all aspects of the identified weakness.
Individual Weaknesses One SSS and one ASSS did not demonstrate satisfactory performance due to individual weaknesses or error s.
As described below, both individuals were unsatisfactory in the use of procedures.
Additionally, the ASSS did not satisfactorily perform the STA function.
Following a simulated Loss of Coolant Accident (LOCA), actions were being taken in accordance with EOP-10, Drywell Flooding, to restore water level in the reactor vessel and to flood the primary containment.
With water level increasing, at approximately -120 inches vessel level, the SSS direc-ted that injection via the feedwater system be secured.
When the injec-tion source was secured, the reactor vessel water level began to decrease.
This action was not in accordance with EOP-10, which directs the SRO to wait until drywell water level reaches 0 inches (which corresponds to 0 inches reactor vessel water level) before securing any injection sources.
During the post-scenario critique, the SSS stated that he secured the injection source because he was concerned about exceeding the Torus Load Limit (specified in the actions for torus level control in accordance with section 7 of EOP-4, Primary Containment Control).
The SSS did not heed the caution in EOP-1, General Instructions, which states that a direction to flood the drywell in accordance with EOP-10 overrides the torus water level control actions specified in EOP-4, section 7.
The SSS was deter-mined to be unsatisfactory in the use of procedures because the procedural violation, termination of drywell flooding below the level specified in the EOPs, was a significant error which impeded plant recovery and could have led to unnecessary plant degradation.
In this instance, the ASSS was fully aware of the fact that the SSS had terminated drywell flooding prematurely.
The ASSS concurred with the SSS's action to terminate drywell flooding; and, therefore, the ASSS was al'so determined to be unsatisfactory in use of procedure.5 During the LOCA discussed above, the ASSS directed the actions specified in EOP-4 to protect the primary containment and as a result he was not fully aware of the status of the plant nor of the actions being directed by the SSS.
During followup questioning, the ASSS did not know what injection systems were available at the end of the scenario.
He was also unaware of many of the actions that had been directed by the SSS in accordance with EOP-2, RPV Control, and EOP-10.
During emergency situations, the ASSS is expected to assume the role of STA and provide assessments of plant conditions and recommendations to the SSS.
The ASSS must be aware of plant conditions and actions taken in accordance with the'OPs to provide appropriate recommendations.
In this case, the ASSS focused on the primary containment and did not provide assessments of overall plant conditions.
The ASSS did not adequately provide assessments and recommendations to the ASSS and therefore was determined to be unsatisfactory in fulfillinghis responsibilities for assisting the SSS in directing shift operations.
Simulator Fidelit In general, simulator fidelity was very good.
Enhancements have been made to the plant specific simulator to more accurately model
'.he severe transi-ents that are required to train and evaluate operators on all aspects of the EOPs.
Training department personnel were knowledgeable and proficient in operating'he simulator.
During validation of the scenarios, a discrepancy was discovered between the control room panel configuration and the controlled drawings for the Emergency Condensor (EC) Vent radiation monitors.
As a result, one of the prepared scenarios could not be used for the evaluations.
The licensee investigated the problem and determined that the drawings and the simulator model were incorrect and that the control room panel configuration was correct.
A deficiency report was initiated to correct the simulator model of EC Vent radiation monitor configuration.
3.0 Review of Unresolved Items Several unresolved items identified in previous NRC inspections were re-viewed as part of this inspection.
The results of these reviews are as fol 1 ows:
Open (220/88-10-01, 220/88-10-02 and 220/88-10-05):
Incomplete requalification training, failure to notify the Station Superintendent of missed training, and effectiveness of the Quality Assurance program in identifying and correcting deficiencies in the requalification program.
These issues were determined to be violations of NRC requirements.
The
'violations are discussed in the Notice of Violations (NOV) issued on
September 22, 1989.
These items are open pending review of the licensee's response to the NOY.
Closed (220/88-10-03):
Deficiencies in management involvement in assuring requalification program effectiveness and compliance.
The licensee revised Nuclear Training Procedure (NTP) 11, Licensed Operator Retraining and Continuing Training, to address NRC concerns identified in Inspection Report 50-220/89-11.
NTP-11 has been revised to more clearly define responsibility for ensuring that missed training is completed.
The procedure also describes a m'ethod for evaluation of operators that meets the intent of performance evaluation.
This item is closed based on these findings.
Closed (220/88-10-04):
Omissions in operator license renewal applications.
The training department has made changes in their tracking and documentation processes to ensure that information provided on license renewal applications is complete
'and accurate.
The Nuclear Compliance and Verification group performs an independent check of the applications prior to submittal.
Additionally, the licensed operators under stand their responsibilities with respect to submitting complete and accurate information on their license renewal applications.
Based on these corrective actions, this item is closed.
Closed (220/88-22-05):
Lack of Quality Assurance (QA) involvement in the EOP development and review process.
Administrative Procedure (AP) 2.0, Production and Control of Procedures, has been revised to include the QA department in the review process for all EOPs.
The QA department also observes simulator walkthroughs of the EOPs by plant operators and performs in-plant walkdowns of selected EOPs.
Corrective actions have been taken to ensure that QA is effectively involved in the development and review of the EOPs, therefore this item is closed.
Closed (220/88-22-06):
Procurement of safety related versus non-safety related operator training services.
Training procedures have been revised to require SRO certification for instructors participating in licensed operator training.
The licensee also committed to incorporate the same requirements into all contracts for procurement of licensed operator training instructors.
Review of instructor qualifications indicates that the instructors meet the established technical qualifications and are adhering to procedures for maintaining their technical and instructional qualifications.
This item is closed based on the above review.
Closed (220/88-22-08):
Concerns as to the adequacy of EOP training.
The results of this inspection and the previous evaluation of operator performance in Hay, 1989 indicate that the licensee is able to adequately train operators in the use of the EOPs.
Isolated weaknesses were identified, but no programmatic concerns exist that would indicate that h
i the operators could not effectively implement the EOPs.
This item is closed based on the results of the operator evaluations.
4.0 Ins ection of Im lementation of NRC Bulletin 88-07 and Su lement
BWR Power Osci llations NRC Tem orar Instruction 2515/99 4.1 An inspection was conducted to evaluate the implementation of NRC Bulletin (NRCB) 88-07 and Supplement 1 to this bulletin.
At the time of the inspection, the licensee had not completed implementation of the actions specified in Supplement l.
In a letter dated February 1,
1989, the licensee committed to completing the implementation of the bulletin prior to restart of Nine Mile Point Unit 1.
Procedural Im lementation The inspectors reviewed the procedures that were written or revised to incorporate guidance on power oscillations and discussed these changes with the reactor analyst responsible for implementation of the bulletin.
Two procedures were developed to address power oscillation; Special Operating Procedure (SOP)
13, Unexplained Reactor Power Osci llations, and Reactor Operations Instruction (ROI) 3,"Thermal Hydraulic Instability.
SOP-13 is the governing document that is used to monitor and mitigate power oscillations.
ROI-3 provides background information on thermal hydraulic instability.
These procedures adequately provide for prompt corrective actions to terminate power oscillations.
'
group of STAs reviewed the Operating Procedures (OPs) to identify situations that could result in entry into the restricted zone (the
"detect and suppress" region of the power to flow operating map).
Temporary changes were made to the identified procedures to include a
caution to avoid the restricted zone whenever possible and provide guidance on the procedure to be used if entry into the restricted zone occurs.
Temporary changes become permanent changes following SORC approval.
Several errors, mostly clerical in nature, were identified in these procedure changes.
The only deficiency noted was that the procedure for emergency power reduction, contained in ROI-1, General Reactor Operations Instruct'ions, did not give clear guidance to avoid the restricted zone.
The reactor analyst responsible for implementation of the bulletin is aware of the identified errors.
4.2 Installed Instrumentation Review of the licensee's documentation regarding the adequacy of the instrumentation used to detect power oscillations indicated that the installed instrumentation is adequate for this purpos a3
~Trainin Review of training documentation indicated that operators were briefed on the LaSalle event in a timely manner.
Training was provided in response to NRCB 88-07 during licensed operator requalification training in 1988.
Additional training to address Supplement 1 to NRCB 88-07 was ongoing at the time of the inspection.
5.0 Observations during the evaluations of the operators on the simulator indicated that the deficiency identified in the May 1989 evaluation con-cerning an inconsistent approach to avoiding the restricted zone had been corrected.
Both crews attempted to avoid the restricted zone and took immediate action to exit the zone when it was entered dur to equipment failures.
Both crews inaccurately diagnosed power oscill.ations and imme-diately scrammed the simulator.
This indicated that the operators were sensitive to detecting power osci llations, but also supported the generic weakness of failure to use all available information to diagnose condi-tions, since no power oscillations actually occurred during the scenarios.
The CSO on both crews reacted before the operators had fully assessed conditions and therefore imposed an unnecessary transient on the plant.
6.0 An exit meeting was conducted on September 29, 1989 at the Nine Mile Point Training Center with licensee representatives (listed in section 1 of this report).
The inspection scope and findings were summarized at the meeting.
Appropriate remediation for the individuals that did not demonstrate satisfactory performance was to be defined and administered by the licen-see.
The licensee questioned whether the results would have been the same if the same performance deficiencies were observed on a requalification examination administered in accordance with ES-601.
The NRC stated that the evaluations had a different purpose than requalification examinations and therefore, the results of the evaluations could not be correlated to evaluations in accordance with ES-601.
Followu Conference Call A telephone conference call between NRC and licensee representatives (listed in section 1 of this report) was conducted on October 4, 1989 to discuss the results of the evaluations of operator performance.
As a
result, the licensee gained a better understanding of the evaluation criteria used during the evaluations and the nature of the identified individual and crew weaknesse UNDERSTANDING/INTERPRETATION OF ANNUNCIATOR/ALARMSIGNALS DID THE CREW:
(a)
NOTICE and ACKNOWLEDGE alarms, and ATTEND TO alarms in order of their importance/severi ty?
All alarms that directly related to significant changes in plant conditions were noted Failed to hotice 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'etermined.
what failures/events alarms were indicating Minor. inaccuracies in alarm interpretation 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 alarms Minor lapes in alarm verification, but no inappropri'ate actions taken as a result of inadequate verification Verification of failed systems was poor or altogether absent SCORE ON UNDERSTANDING/INTERPRETATION OF ANNUNCIATORS/ALARM SIGNALS:
Satisfactory Comments:
Unsatisfactory
DJAGNOS'S OF EVENTS/CONDITIONS BAS D
ON SIGNALS/READINGS DID THE CREM (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?
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)
Correctly DIAGNOSE plant conditions based on those control room indications?
Diagnoses hy crew were accurate and timely
.2 Minor errors/diffi-culties in diagnoses Faulty diagnoses resulted in incorrect control manipulations SCORE ON DIAGNOSIS OF EVENTS/CONDITIONS BASED ON SIGNALS/READINGS.
Satisfactory Unsatisfactory 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 knowledge 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?
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 team Crew appeared to act without knowledge of or disregard to, effect on plant SCORES ON UNDERSTANDING OF PLANT/SYSTEM RESPONSE:
Satisfactory Comment:
Unsatisfactory t
CO!'1PLIANCE/USE OF PROCEDURES DID THE CREW:
(a)
REFER TO the appropriate procedures in a timely manner?
'rew used procedures as required; knew what conditions were covered by procedures and where to find them Minor failures by crew to refer to procedures without prompting, but did affect plant status Failed to correctly refer to procedures when required, res'ulting in faulty system operation (b)
CORRECTLY IHPLEMENT 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 p'rocedural enactment of procedural.
misapplication, bu+
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 I
(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 lapses or errors; individual crew members needed assistance from others to implement procedures Failed to accurately recognize conditions or execute actions, even with use of a>"ds SCORE ON COL 1PLIANCE/USE OF PROCEDURES Al'D TECHN I CAL SPEC I F I CATI ONS:
Satisfactory Unsati siactory Comments:
I'IDTHE CREW:,
CONTROL BOARD OPERATIONS (a)
LOCATE 'ONTRO'
e ffi c iently 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?
Smooth manipulation of the plant within controlled parameters Minor shortcomings in manipulations, but recovery from errors without causing. problems Mistakes made in
'anipulating controls caused system transients and related problems (c)
Take MANUAL CONTROL of automatic functions, when appropriate?
'3 Al 1 operators took
~
control, and smoo hly 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 anple time and indications existed SCORE ON CONTROL BOARD OPERATIONS:
Satisfactory Unsatisfactory Comments'.
>
DID THE CREW:
COMMUNI CATIONS/CREW INTERACTIONS (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 i)embers were
~ inattentive to what was happening around them; poor coordination of activities (c)
MAKE TEAM DECISIONS in a'imely, effective manner.
All 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 effective decisions Leader or other crew members did not accept input from others, resulting in incorrec+
or untimely decisions/
directives SCORE ON COMMUNICATIONS/CREW INTERACTIONS:
Satisfactory Unsati s factory Comments:
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V Nm~ diff-culties in a tending to or prioriti-ing attentim Failed to attend to/prioriti"e important alarms:
slow response and/or distracted by nu: "-:.~ce alarm-.
N@W5y ItPER% T th reuing "-d signi-.icwce of alarms and am~to~'?
K~c3:ly ask w"Iat Y'-ar ir"IaCcuracieS/SCFse delcryS ln ala irI lrrtel P e ti~
r"3isinterpretaticns.
d lays or misuse of MCs res Ilted in pla-Cegradaticn.
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(-'~fXR'I/F D----D=- I ti ends/statLls:
~ck ~ accura e r&:sAvlxt?Gn r Rv6 delays ii\\
recognizing of formal condi icns.
SpL!r1ous 9Tllsslons e
delays of inaccuracies in recognition.
(b) En~ th col lecticn of AFFECT, AXLE,E and ~FLE,e. in ore=-,tion and I'. %Ence Itiate lal LII.m I'~hie'",
o 'base diagnom7
&au;e t?iat all re~ p/cA i Lndxcat1D is and references I%~re c? eel:M.
?'i3.r Ior 1I 1st ai"ICes OT ovel lotA.'itig >
overreliance c
misinterpretation of indications and or reference-.
S rir~s instances of Tallul e to LICe DI-xW i. Dortant in.ormtico or A'ilsL'Lse Di data+
(c", Carr+
ly DION~ plant ccnditions based cn ccn rol re~i indica icos?
DL~io~,Vk~ie accut ates minor errors/
difficulties in dlaci"Iosls FaLI1ty diagnosis adversely xITipactcd plant status Satisf actory Lllsatis i ac tory g n (J~TA'GI'i% CF FUN/SYSTBi FF~~"~f'~Z
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'b ~,~'p-KM the STATIC'I -HI. T P~F~VI~i:
(83 i~< = contro'em-.. info';~tie-, corrc~f'.y ~nd e~-ici~'
o ascertain
~~) vc'. iTv the status/cpei atl(vi,": i pirYit syst ~'fis (
kxm~~ and PA~85%t W46%%41on
~IR~Ff&tat3.on Ninor errors in interpreting in ioAAaticnr Sel 1ols oni1551onse delays or inaccuracies in information interpretation.
(b~ ~~ A~~IVF to control room indicaticns'?
~y ~an'Red 1 KR~C'AS, ant1cRpRted cl v3nges in~ conditions
~ 49>>vents 1in Sporadic scannina of indications: minor lap~~
3Jl anticipating predictable chug~~.
Fareiy scanned lndicaticNl
) fa1 led to an icipate predic -ble ctvvges in plant status.
(c) Rostra e through directives and acticns a thorough QZMPA)lhG of hx J.
F44,~, SYS~e.,
and CRFCb84S op rate and interact?
Daums rated th-Ough
~, WEBER idir Lg Of i QN
~"carpcnents OPR~
intaraur Nina; instances o
errors due to gaps in km~ledge of hue systems/c~ents op ram.
P InadEQLl~te Li"howledQP of systee/coeponent
.
opration resulted in serious mistakes o,.
plant degradation.
Satisfactory Lhsatxs ac to-y CCNWPP.
~
~
L
~ '
CO ~ 'LIAAF/U=E CF FR~FCS Md th ~~oATICN &GFT ~M'v>IBM:
,EC i~~ i>O CGI rei t pi C edui ES c!ind Oi Kedut al Ste>pe Wean appi 0+~iI i>.te?
R~e~.m5. readi1y agprop rosie pH3ced>~cps as AKESsaITI>>r Ninor lap~> in re,erring to/
locating appropriate procedures.,
F~led to correc ly refer to procedures in important instances.
>8 LEBRG~~M Z+K4'
inc~lvdlfig fQlloIring proc% J al steps in co~ Mguence< c.bldlng by pl Qced'lra cckltiDls and limltationsi selacUng corre-t paths on decision block:s and correctly transitioning bet~1 pi ccedul es?
~r~ ~~Irate.
ly~talent of E>~TRa StEPS e
Minor errors, but made necessary correcticns in timely fashion->.
Significant Erro,
~
which led to imp=-ded/
slow recovery a&/or L'v ir IEcE'ssairy plant degl adatlcnr (c) Ense th=- safe efficien INLYENTATIP! of procedure-by the K~4?
s ~6~~
~rv~
dlrEc01aKM provld&c.
~ Ve era" ior
~~~!=ty. If dxracw~ are given ta Crew-3rrfOrm SS.
All~ lap~~ in implementation by the crew.
Rea J pi ccEcures zo him~1f: failed to ore l-a"trate/verify L(se 0 i pi >ocedLIres crew friebers.
Satisfactory Lhsatisfac tory BZc
>>a! L~~i~ic>>. ~e i. >
a> clea.
easily unde;st~& n.-nner">
Cor.~ i"-.s vere a"4 "" ~r a-"
u>>dRC~M Id At tines
> CCii> ~ >> >~> 8 iic> >S i>> >>~
confusin,,,
hard to heal ol understand r
'"~nicaticns were
' l t3.lpJ>> va ue and/or difficul to hear of interpret.
(b) ~ crew ncrIb rs and those outside the ccrltml room informed o. plant
~~~'?
ProvM others with accLM~'
parting infor
'cn ttr ~lt scenario.
t"incr instances of needing o be prompted for info; sore incomplete inaccurate info.
Failed to pravide needed informatics.
{c) B~M~
F~CEIPT of clear easily understood conrUnications from the crew a~si others?
Reql.lesm infcrmaticn c a if'*icxlw Ri l.ec~c~c.
und~~ds cor>>Ucatlcns from othe. ~
Minor instances of
>all1no to I Egull e or ache+}edge info from others.
Failed to requ st needed i>lfo o'
inattentive when info was pADYLded! Sel l.ous mi-Inders msding anang th c~
Satin~ ory Lhsatisfactory CD'PR'S:
r<<
Did ttw~~TI~
HIFKSWH~VI~
- <<
(a) Ta5~VI,"H Y. DECISI'; P TIQ~ w,"cr, problem.% aro:,-'?
Tcek ar2.-," remedial recce)akr'e acticn when AQKKsa<<ry ~
ilinor instances o
failing to take acticA within l eascAable pel 3.od of time,
~ allure. to tak<<e iy acticn resulted in deterioraticA of plant, conditions.
(b) Ptmdh TIt~Y, lM~
T'r'<<3~Wi Q7 Dihc: ill'2 that facilitated era~
perPprance and darcAstrated appropria e ccncern for the safety of th Plex i~ star f p and P Ibllc?
Direct=~~ enabled safe, <<Mrated crew per ~amerce.
Minor instances of in orrect, trivial or,dif.icult to carry out orderss.
D1rect1ves lnrh1bited safe cl eW pe ornance:
crew had to e plain why orders couldn't or s,"ru1dn't b folim =d.
(c) St-in a pc=-iticn of DvERSITE providing an apprcpriate am:nt of Direction arid C~ adance?
Sayed a-..mlved, but Hl,ihcFda. Irexng too 3Ji iAISl.~g anticipBM D ew needs ~KI provided gL<<i~~
neo e55apjr Crew had to solicit
'ssistance on occasicA, interferir g with their ability to Carry OUt actiCnsr Lost. the biq picture: crew had to repeatedly request/
prov3.de gul.dziice!
failed to verify corr ect enacbrcnt of dire=tives.
<<
(d) K2VT -J-d i':6$- WTE FEDiAD frcxn crew to foster e~~ a ientated ap"roach to prob1cm solving(decision an "effectlvec
<<liat<<i1nq Involved cxew 'in problem saiJV3ng prccess w appropr~,
leading o eff~ve team.
decisicn eel;ing..
At tiftcm, failed to involve crew in decisicA making wh=-n it wo <Id have tan appropriate,
"
" '
detracting from team orientated approach.
ihcisicAS made without needed crow participat3.CA or consul tat3.~: crew divisivRless was counter-produ tiv Dio~ AKISTPHT b~ATICN SHIFT SLFERVIRR:
ta) ~iCE and ATTB4) to amuncia or/alarm siana}s in order of their-v-t-yc/--- -~ -'y~
Achy and eff;.izRrrtly, in all XASCiiRKKRB Minor dif.iculties in attending to or prioritizing attention Failed to attend to/p;ioriti=-e important alarms; slow response and/or distra-ted by nuisance alarmse--
-~
(b) Gently INTERACT th ~ing ~~d significance of alarms and Kt'4piclato 5P Und~~~/quickly dPSQALTAed what faiR-.=m alan'
re inNxi~
Ninor inaccuracies/some delays xll alarm interpretation.
I'1isinterpretations.
delays or mia.ee of PRCs re~<lted in plant degradaticn.
(c) WFY that -nmuciator/aiarn sionais were consistent.
wit1-plant/system
~l,tlons 7 Enmre~r veii~ticxl wi pn nc~~,
Sat~story
'"inor lapses in alarm verification, but no inappropriate actions as a result of inadequate, verification. '
, ~.
Lhsatisfac tory Fangled to verify and or improperly verified on importa lt occasions e
didn'. notice
.
. inconsistency between alarm>> and plant condition Kl DIAL'GRIS Ci= EVihTS/CQC)ITI(M B'GEO CN S18'4%$, F~~AOINM Oid tl-e ASSISTANT STATIC &LIFT ~~'WERVIWA:
(a) MGXNIZE o
.~orreal trends/s atus?
GLJLcli and accus ate recce. siticn e Scxe delays in remi=.ing off~annal conditions.
Sxo icUs DAiss1cnsm delays of inaccuracies in recooniticn.
(I53 En@.m tho collection of CCP~T, PP~RAYx and K"T=~e, info. ~,etio-~ ~".<- ~-
refemze materia.
up=n which -o 't-se diagnr=.c~,
Enure Jet ai 1 relpvcvlt indications anted references ~re checked.
Ninor i-.stances o
over lee):ing.
overreliance on misinterpretation of indications and or re eren-es.
EBl iou Instances of fai iud e to use ot mioo infol maticn ol misuse o-data.
(c) Correctly DIAL-e. plan ccndi icns basal on control rccm indications?
Diagno~ ~are acculater ilinor errors/
difficulties in diagnosis Faulty diagnosis adversely imph "M plant sYatuse
.-~satisfactory Lhsatisf ac tory cl'
0
0+DEFSTAZ>lloyd'
F~~
> i&'STEN F~~SFD~
r Did ~J-a A~ISTAVT STATICN S",IFT BWMVIMR:
I('<<I <<
ia) If'~PET cc((.+rol room indica ors correctlv and efficiently to ascertain a >d ~i.'. jy t'"r".r status/G ral Bt c l Gfi p3 ant systPT>s (
AccuraM effichmk instn.vrent and cUsy~ay 1ntei Pr rrKBtiCXl Ninor errors in interpreting inst'.events and displays.
~~1~ Gmlss1ons>>
delays of inaccuracies in instrument and display in er~~""tiGA (b3 Ream A>>v IVE to control race indicaticns?
Regula@ s-armed 1ndicaM~S j antics+ted changes 1r 7 Plar(rrr. CC>ld1tlCXls due tO KABltS 1r
>
pr-rc~~
Spol adlc scanining of indications: minor lapses iA ant1C1PBt 1rlg pred'
table ch=-vlge-.
Rarely scanned indications j failed to anticipate predictable changes 1fl plant status (c'. Demstrate through dirEctive and actims a thorough NDERSTANDI¹ o trna th FKXA~i, BYS~, and CCP~~iS op rate and interact?
D--.>m~ted through unde~ding of l-aw sys ~~exponents oper Bte clp~
inter'inor instances of errors due to oaps in 1~%16dge of hc}Lv systems/ccx~porv=-nts op raw.
lnadeqcm~ k~ledge of system/component operation resulted in seria.m mistakes of
'lant degradation.
Satisf ~w~
CXN GAL 0-satisf ac tory 4 i(
~ (
'(
V<<
Mf.ilCKE/LEECF r".FJ.eZ(
cS Did the SGSISTA'i~i STA. I<A B-:IFT P FERVIRR:
(a) R2R tc correct procedures and procedural te
>
Facy.~~ted! read'y lccated al 1 a~~ate pl ocedupes as necessary
~
I')inar lap~ in referring to/
locating appropr iate procedures e
railed ta coo rectlv refer to procedures in important instances (b) L'=ED.=~i~ RE< CC~~Cl<Y, including following p'acedu. al steps in correct sequence, abiding by pracEkll al ca'tians Gild limitatiansp
~la ing correct paths on decision biccl;s a;d correc lv transiticning procedure~?
Ensured accurate, timely enact-ent of pracedural steps.
Minor errors, but made necessary corrections in tirrely
. ashian.
Significant errors which lcd to impeded/
slaw recovery and/or u, >necessary plailt Cegradaticn.
{c) Ensure the safe efficient IIPMENTATIOWof pt ocedu< es by the KSP.
Kept HK md crew in. orated of procedural status:
got acfcn~ledg~mt fram crew @Am reading prccedure-.
SBS cccasianal ly had to question AKS regarding status:
~
allowed lap~~ in ingle'=-station by t,"a crew.
Read procedures to him~if: failed to orch=etrate/veri y
use of procedures by crew ITppi)a~ ~
Batisfactor y D:C'Z'$4TS:
Lhsatisfactary
.z/
C ~~.) NICATID~ X CFa IWn~TIa~
Did tte KSISTAIPi STATID'I ~i."
~ -=i KVIFR:
(a) ~iiCate in - Clear.
Bas11y K'-. lde'tccd ii-rineÃ7 Conmamkm~ons ~re tirraly Wear-cut, and easy to hear and undersIIaiAd At tirre=-
CMiA.v'licatiOnS WBl e confl.M~Q hard to hear or i.aderstand.
Ci~iTF inicaticns 4P re ilI-tired . vague and/or difficultto hear of interpret.
(I3r I &~crew (&5 Gl s a/'d those D ltside th contt ol I oM
~ in cPHcw o pla-,t" sta&~?
Provi~ others with accura~
p rt1n-"n 1nfCA&~a t~ehutt. scenario.
I".inor instance of ne=dil ig to be promp ad or info:
axP in ceplete inaccurate info.
Failed to pro'ioe ilc& d 1ilfoiriiati~&
I (c) e~&S FECEIPT of clear easily understm cnxwications fr@~ the cree'i tJ cxChBrs?
FRguests 1flfoAMticn clal 1f3.Mi.ccl Hi Fn neces~
idlers~
' cmrn nications ram others.
i Iinol 1>> istances of fa1lli"ig to rKju1t e or acknowledge info froe others.
Fai}ed to PEcjuest nmkd info or inattentive w,"Pn info NBs pl ov1ded seriQ.'6 nisunde'standing aiiig the c~
Satis'factory CQ'MTS=
Lhsatis fac tory gl
h DIRECT
~ )IFT Ct-WAi ICf4~
Did he AKISTQ~i STATICN %IF i RFWVIKyi..
(a) Tak~ TI!Q Y PECISIW'E ICN wW<, arab'.c~.
"v==..
a Taak early renedia3.
recu per atLve acticn Wilen neCeSSary e
Mino- '-
an"e= a failing to take action within reasanable period of tine.
Failure to take timely action resul ted in deterioraticn of plant conditions.
(b) Provide 'TI."K Y, KEiJ TH3 &Pi O 'T RE~~'&~'C<~~
~W DIRECTI~ that
.a-ilitated crew performance and derer<strated appropriate concern for the safe y o th plant, sta,, wd public?
Rcccmlendatians or di~tives enabled safe.
integrated cree
>
pep fence Minor in=- ances of incorrect. tri.vial ar dlfTlcult ta
. carry aut aci~s.
Recanrrendatians and directions inhibited Pet iallMilce CreW ta eriplain ~i action cauldn'
o-s"jauldn'
be falIc~ ~
{c) Stay in a pa=--iticn of GVPHITE providina an aoprapriate au nt of Direction and Abidance?
Stayed involved, but
withau being tao lntrus3.ve!
anticipated c~
n~s and provide"
~
guida~e when necessa Crew h d ta solicit
= assistance an o casian.
interfering with th ir ability to carry aut actions.
Last the big picture: ~ had to rep=-notedly recp.e"=t assistance:
failed to verify correct enactnent of KS directives s Involved crew in problem salving prc ess as appr priate, leading o effec ive team
'ec151an making e (d)
r(ICIT and ItG7&AA~FEEDB40i from crew to foster team orientated approach ta problem salvira/decision r/
"C
..-
'=-'. '~At-'tines. "failed to
~.'":involve c~~w in
., " -'-'eclslan making 'e rn it.m <ld have L zen
~
~
~ appropri'ate.
. -.- ",,detracting fram team
'rientate-'pproach.
an effec~~ve.
making?
De=isians rade withcvt ncM=d crew par ticip=tian or cansul tatian, crcm dxviszveness was coun er-productive.
4