IR 05000245/1992027
| ML20125D841 | |
| Person / Time | |
|---|---|
| Site: | Millstone  |
| Issue date: | 12/03/1992 |
| From: | Conte R, Florek D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20125D824 | List: |
| References | |
| 50-245-92-27, NUDOCS 9212160063 | |
| Download: ML20125D841 (11) | |
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U. S. NUCLEAR' REGUIATORY COMMISSION
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REPORT NUM.BER: 50-245/92-27 DOCKET NUMBER: 50-245 LICENSE NUMBER: DPR-21
' LICENSEE: Northeast Nuclear Energy Company P,0 Box 270 Hartford, CT 06141-0270 FACILITY: Millstone Unit 1 Nuclear Power Station INSPECTION DATES: November 3 - 6,1992 ACCOMPANIED BY: D. Desaulniers, Engineering Ps chologist, NRR b
LEAD INSPECTOR: Y k)
bonald Florek/$r. Operations Engineer D/te /
BWR Section, Operations Branch Division of Reactor Safety APPROVED BY: M e. %/ E b Richard J. Conte,f2hief Date i BWR Section, Operations Branch Division of Reactor Safety INSPECTION SUMMARY: Examination /Insoection conducted November 3 - 6.1992 L (Inspection Report 50-245/92-27)
AREAS INSPECTED: Special announced examination / inspection to administer retake .
J- requalification examinations to 3 operators and I senior operator, to evaluate if stress was a causal factor of the crew failure during the week of September 21,1992, and to verify'
l facility licensee actions to comply with item 4 of Confirmatory Action Letter 1-92-014.
I 9212160063 DR 921209 ADOCK 0500024 PDR-
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i RESULTS: All three operators and the senior operator passed the examination. The examination the week of September 21,1992, provided valid insights of weaknesses in the failed crew's knowledge and teamwork skills. Stress was not a singular cause of the crew's failure but was a causal factor that exacerbated the performance problems caused by these weaknesse The licensee has complied with item 4 of Confirmatory Action letter 1-92-01 _
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DETAILS r INTRODUCTION Examination report 50-245/92-23 (OL) documented the unsatisfactory Millstone Unit I requalification program evaluation. Following the unsatisfactory program evaluation, a Confirmatory Action Letter (CAL) 1-92-014 was issued which restricted those licensed operators who failed either the NRC or facility requalification examination until either the facility requalification program was determined to be at least provisionally satisfactory or until the licensed operators have been evaluated as successful by the NRC. On November 4,1992, the NRC staff administered requalification retake examinations to 4 licensed operators (3 ROs and 1 SROs) who had failed facility requalification examination The 3 ROs were administered a written examination, and the SRO was administered JPMs to evaluate his ability to properly classify an event. The JPM methodology was used in lieu of classification in a dynamic simulator environment. The examiners used the process and criteria described in NUREG-1021, " Operator Licensing Examiner Standards," Revision A listing of the items used in the examination is contained in Attachment Also, an inspection was conducted to evaluate stress as a causal factor for the crew failure during the requalification examination administered the week of September 21,1992. At the October 7,1992, exit meeting for examination report 50-245/92-23 (OL), the licensee indicated that the root cause for the crew failure was examination stres F irther, the inspection also assessed whether item 4 in CAL I-92-014 was accomplished by the licensee. Item 4 required the licensee to construct the remaining 1992 requalification written examinations using the process developed for the October 2,1992, written examinatio . -
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4 SUMMARY OF EXAMINATION Individual Examination Results NRC GRADING
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RO SRO TOTAL, Pass / Fail Pass / Fail Pass / Fail m
Written 3/0 N/A 3/0 Simulator N/A 1/0 1/0 Walk- N/A N/A N/A through Overall 3/0 1/0 4/0 Weaknesses Based on Individual Operator Performance A summary of the weaknesses noted by the NRC staff during the grading of the written examinations is discussed below. This information is being provided as feedback to the facility licensee in improving the requalification remediation program, The following generic weaknesses on the written examination are based on more than one operator not answering the question correctl Knowledge of the effect of closure of the CRD flow control valve on CRD flow to the vesse Knowledge of the vital MG set conditions on the AC drive, i
! - Knowledge of the loss of 480 bus 12E with the vital AC bus on emergency bu Knowledge of the diesel generator operational loading restriction Understanding of the recirculation pump trip logic on a high drywell pressure.
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- Understanding the effect of closure of 1-IC-5 on operability of the isolation condenser.
I Each one of these weaknesses was identified by the facility licensee as duty area that was an l unsatisfactory area in the 91-92 requalification cycle for one or more of the operators examined. These weaknesses suggests that the self study approach taken by the facility licensee remediation program was not completely effective in at least the above area .0 EVALUATION OF STRESS AS CAUSAL FACTOR IN REQUALIFICATION EXAMINATION CREW FAILURE Background During the week of September 21,1992, the NRC staff conducted requalification examinations and a program evaluation at the Millstone Unit 1 Nuclear Power Station. One operating crew was rated unsatisfactory. Three members of the crew failed individually and the entire crew failed overall during the performance of a dynamic simulator exam scenari Representatives of Northeast Nuclear Energy Company met with NRC staff at Region I on October 7,1992, and discussed the results of NNECo's root cause analysis of the crew failure. The NRC staff questioned NNECo's root cause determination that related the failure of the three operators to examination stress. The NRC staff subsequently conducted an independent evaluation of stress as a causal factor in the crew's requalification examination failure. The NFC staff review was conducted by a Senior Operations Engineer from Region I and an Engineering Psychologist from the Office of Nuclear Reactor Regulation (NRR).
Scope During the week of November 2,1992, the inspectors reviewed the " Millstone One Licensed Operator Requalification Examination Failure - Root Cause Investigation Report" and interviewed the five members of the crew that failed the dynamic simulator portion of the examination. The inspectors also interviewed two individuals that evaluated the crew during the examination, the Manager of Operator Training, a member of the training staff that helped the crew prepare for the examination during two weeks of simulator exercises prior to the examination, and a contract behavioral specialist who observed the crew as they prepared for the examination and who conducted interviews with the crew members following their failure of the examination. Interviews with the crew members were focused on determining the basis for the actions they took in the dynamic simulator scenario that the crew failed, and determining the factors they believed affected their performance. Interviews with the evaluators and observers were used to verify the activities of crew members and determine if they observed behaviors that suggested stress was a causal factor in the crew's performanc Description of Sintulator Scenario and Crew Actions The dynamic simulator examination scenario that resulted in the crew's failure was a Loss of Vital AC with a small break IAss of Coolant Accident (LOCA) in the drywell. The Loss of
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Vital AC caused a loss of many control room indications, including the reactor water level and reactor pressure indication on the control room 905 panel. Power was also lost to the feedwater regulating valve indicatio in response to the loss of vital AC, the reactor operator (RO) monitored reactor water level from the ATWS panel, a back panel. The feed pumps were secured as reactor water level returned to normal. The feed pumps subsequently restarted in response to the small break LOCA. The feedwater regulating valves (FRVs) were approximately 50 percent open, where they had locked-up on the Loss of Vital AC. The loss of vital AC caused the FRV indication to read that the FRVs were closed. The RO continued to monitor reactor water level by running back and forth between the 905 panel and the ATWS panel. Level indication at the ATWS panel increased to 50" (top of scale). The RO continued to report reactor water level as 50 inches. The reactor pressure vessel eventually filled and pressurized causing lifting of the Safety Relief Valves. No member of the crew realized that the reactor pressure vessel had been filled and pressurize It should be noted that this same crew performed well in their second scenLo. However, the focus of this review was to better understand the poor performance on the first scenari Factors Contributing to the Crew Failure Based on the data obtained during the interviews, the inspectors determined that the following factors contributed to the crew failur Knowledge weaknesses:
Feedwater Regulating Valve Indication - Crew members did not know that loss of vital AC caused the feedwater regulating valve indication to fait down scale. As a result, this indication provided misleading information, causing the operators to believe that the feed pumps were not injecting when in fact they were feeding the reactor pressure vessel at approximately 100 percent flo Flood-up Level Indication - Crew members did not realize that an alternative to the ATWS level indications was available on the main control board. The flood-up level indication provided wide range level indication that could have been used to verify the level indications provided at the ATWS panel. Observation of the flood-up level indication would have allowed the crew to recognize that reactor water level had exceeded top of scale on the ATWS indication Procedure weakness:
Loss of Vital AC Procedure - The Loss of Vital AC procedure directed the crew to use the ATWS indications for monitoring reactor water level. The procedure did not reference the flood-up level indication as an alternative level indication. Use of the flood-up level
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k* 7 indication would have enabled the crew to recogn ize that t hey were flooding the reactor _ 4
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pressure vessel and secure the feed pumps. Use of the flood-up level indication could have also reduced the amount of time the RO was away from the main control boar Crew teamwork skills:
Crew Dependance on Shift Supervisor (SS) - Performance of the crew in the loss of vital AC scenario suggest that the crew may have become dependant on the SS for supporting effective '
crew interactions. Early in the scenario, control room indications following the loss of vital AC confused the SS, and he failed to recognize that the reactor had scrammed. The SS told the senior operator implementing the emergency operating procedures, SCO, to calm down because the reactor had not scrammed. The SCO told the SS that the reactor had scrammed and subsequently the SS withdrew to - , rear of the control room and attempted to re-assess the plant's status. As a result, the SS had limited interaction with the crew. The SCO perceived that he was all alone given the confusion of the SS. Although some crew members sensed that something was wrong, they were unsure of what to communicate and consequently they did not state their concerns to other crew members and they became focused on specific task The SS considers himself to be a team builder, and this perception was also held by members of the training staff and crew. Several interviewees reported that the SS typically talks with each board operator in the course of a scenario and coaches the crew in the process. In this manner the SS appears to serve as an informal communication link between the board operators. During the loss of vital AC scenario, the interaction between the SS and the crew was limited, relative to the amount of interaction normally observed by members of the training staff. Rather than increase direct communications to compensate for the less communicative SS, some of the operators indicated that they lost confidence as the scenario progressed and began communicating les Stress: j Interviews with the members of the crew indicated that the sources of stress, and the level of stress experienced, varied across individual crew members. None of the operators described experiencing extreme stress, but some believed that stress may have affected their performance. Most commonly cited by the crew was stress caused by the implications that failing the examination had for their performance appraisals and promotion potential. This source of stress seemed to be tempered for most individuals by a level of confidence that they would pass the examinatio Several operators considered the large number of observers in the simulator to be excessive
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and stressful. The crew was observed by five licensee evaluators and four NRC examiners.
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Also in the simulator observing the crew were an NRC headquarters representative, an NRC regional supervisor, an individual on training rotation to the NRC, observers from Washington Public Power Supply System, and members of NNECo management. Although i-
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most of the observers were a necessary part of the examination process, the crew was observed by more individuals than normal during requalineation examinations and thus experienced more stress than is typically caused by this aspect of the examination process, interviews with the operators suggest that the most direct effect of the stress of the examination on their performance was inadequate crew interaction to compensate for crew knowledge deficiencies. Although several operators experienced confusion, these individuals were hesitant to express their concerns in tly examination environment because they expected such actions would result in negative evaluations of themselves or other crew member Interviews with several of the crew members hiso suggested that during preparation for the examination they developed personal goals of far exceeding minimum standard for passing the simulator section of the examination. Such objectives may have also caused pressure on the individual crew members to conceal their confusion and concerns so as to appear fully in contro in general, the sources and level of stress experienced by the crew were consistent with those typically experienced by crews in the requalincation examination environment. The notable exception was the stress caused by the large number of observers in the simulator. The inspectors concluded that stress was not a singular cause of the crew's failure but was a causal factor that exacerbated the effects of the previously noted crew weaknesse Conclusion The inspectors concluded that the examination during the week of September 21,1992, provided valid insighf 3 of weaknesses in the crew's knowledge and teamwork skills. The stress en crienced b. the crew exacerbated the performance problems caused by these weaknesses. Crew members failed to express confusion or raise questions concerning plant status and mitigation strategies in the examination environment. These operators expected that such actions would result in adverse consequences in the examination environment. The failure of the crew to A:velop a collective assessment of the plant's status impaired the ability of the crew to compere ta hr individual knowledge or performance weaknesse .0 REVIEW OF WRITTEN EXAMINATIONS TO VERIFY CONFIRMATORY ACTION 1.ETTER (CAI ) 1-92-014 ITEM 4 LQgn) Unresolved item No. 245/91-26-Olh impkinentation of Corrective Actions from A991 requalifnlign program evaltuttmL As described in examination report 50-245/92-23 (OL),cc ations in the facility written examination bank lacked operational orientation, were not at least at the comprehension level, were direct look up question =, did not diwriminate or had more than one correct answe The NRC staf 'luded w . Millstone Unit 1 facility licensee written examination banks are weak eval .. tool !
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Subsequently, the facility licensee prepared an examination question cognitive level determination flowebatt and committed to develop a writers guide for examination constructior The facility licensee applied the Dowchart and used the open reference guidelines of the examiner standards to construct the examination for the week of the October 2,19C. In item 4 of the CAL the licensee agreed to " construct the remaining 1992 requalification written examinations using the process developed for the October 2,1992, written examination."
The inspector reviewed the written examinations given the weeks of October 5, 12 and 26,1992. Each examination contained about 50 questions. The inspector also int:rviewed the individual responsible for the final verification of the examination by use of the Dowchar The inspector concluded that the facility prepared written examinations met the NRC '
expectations in the NUREG-1021 Examiner Standards. The facility applied the flowchart methodology in the development of the examinttions and met the commitment in item 4 of -
the CAL. The inspector identified one question (1503) out of the three examinations reviewed which was a question testing at the memory leve!. Upon review of the Howchart methodology, this question type was not climinated t.y use of the Howchart. The facility licensee recognized that some changes were needed to be made to the methodolegy as a iesult of applying the new methodology to the examination development and would include the modification to climinate a question of the type of 1503 from the examination in the futw The examinations administered during the weeks of October 5,12, and 23,1992 d!scriminated between competent operators and those who warranted remediatio .0 EXIT A1EETING Region I conducted rn exit meeting on November 6,1992. The NRC presented the results of the examinations and discussed inspection related findings as discussed in this report. Those personnel in attendance are noted in Attachment :
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A'ITACilMI'NT 1 ItEQUAl.lFICATION EXAMINATION TEST ITEMS Jolt PEltFORMANCE MEASUllE 61 Classify an Event Using EPIPs STATIC WillTTEN QUESTION NUMIIElt STATIC SSE-09 STATIC SSF 16 472 728 718 1176 873 1373 878 1396 1593 1660 1661 1602 1662 1603 1596 1604 y 1597 1605 1598 1(06 1621 1607 1600 1M2 12 pts 12 pts CLASSItOOM WillTTEN QUESTION NUMITEll 1609 1610 1611 599 1613 1658 122 1616 1617 1618 1595 1620 1599 1622 1623 1624 1625 1626 1627 1628 1629 322 319 1639 292 8 (26 pts)
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A'ITArilMENT 2 PEllSONS CONTACTED NOltTilEAST UTILITIES l
- M. Illack, Director Nuclear Training
- M. Ilrown, Project Manager Operator Training Unit 1
- 11. Ilaynes, Director Unit 1
- R. licidecker, Supervisor Operator Training Unit 1
- M. Jensen, Assistant Supervisor Operator Training Unit 1
- R. Palmieri, Operations
- P. Przekop, Operations Manager
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- M. Ross, Operations Assistant
- 11. Ruth, Manager Operator Training
'C. Tabone, Senior Instructor The inspectors also contacted licensed operators and senior operators and facility training personnel during the course of the inspectio NUCLEAll REGULATORY COMMISSION
- D. Desaulniers, Engineering Psychologist
- D. Florek; " , Operations Engineer
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- Denotes those present at the exit meeting on November 6,1992 i