IR 05000255/1987012
| ML18052B135 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 06/10/1987 |
| From: | Christoffer G, Patterson J, Snell W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML18052B133 | List: |
| References | |
| 50-255-87-12, NUDOCS 8706160709 | |
| Download: ML18052B135 (16) | |
Text
U.S. NUCLEAR REGULATORY COMMISSION
REGION III
Report No. 50-255/87012(DRSS)
Docket No. 50-255 License No. DPR-20 Licensee:
Consumers Power Company 212 West Michigan Avenue Jackson, MI 49201 Facility Name:
Palisades Nuclear Power Plant Inspection At:
Palisades Site, Covert, Michigan Inspection Conducted:
May 18-20, 1987 Inspector:
Q.~~PP\\
d Patterson Team Leader A 1~. Uw.i~~A--
G. Christoffer U--1
'?,l'(t~
i,us~
Approved By:
W. Snell, Chief Emergency Preparedness Sectio Inspection Summary c-Joh Date
~/to/57 Date Inspection on May 18-20, 1987 (Report No. 50-255/87012(DRSS))
Areas Inspected:
Routine, announced inspection of the Palisades Nuclear Plant annual exercise involving observations by four NRC representatives of key functions and locations during the exercis The inspection was conducted by three NRC inspectors and one consultan Results:
No violations, deficiencies or deviations were identified as a result of this inspectio However, one weakness was identified relating to the Medical Drill. This is summarized in the attachment to the report 1s transmittal letter and in Section 4.d of the repor e~g55
~DR ADOCK 0 PDR
- DETAILS Persons Contacted 2.
NRC Observers and Areas Observed J. Patterson - Technical Support Center (TSC), Operations Support Center (OSC) and Emergency Operations Facility (EOF)
G. Christoffer - Medical Drill T. Lynch - DSC and Onsite Radiation Monitoring Teams C. Anderson, Resident Inspector - Control Room and TSC Consumers Power Company (CPCo) Personnel W. Beckman, Radiological Services Manager R. Rice, Operations Manager R. Orosz, Engineering/Maintenance Manager D. Joos, Administrative and Planning Manager P. Loomis, Emergency Planning Administrator; Corporate A. Katarsky, Exercise Coordinator, Corporate D. Fugere, EOF, Health Physics Group, Corporate K. Penrod, EOF Evaluator, Corporate
- K. Berry, EOF Director
- R. DeWitt, EOF Officer J.* Brunet, Emergency Planning Coordinator (EPC), TSC Lead Controller M. King, TSC Controller M. Dawson, Medical Drill Controller G. Ellis, Radiation Protection Supervisor T. Begin, Offsite Controller S. Cote, Property Protection Supervisor T. Anderson, Shift Supervisor (SS)
D. Malone, Nuclear Licensing Analyst T. Neal, Staff Health Physicist L. Kenaga, Staff Health Physicist J. Alderink, Engineering and Maintenance, Staff Engineer All names listed above, except those designated with an asterisk (*),
attended the exercise exit meeting on May 20, 1987..
General
. -An exercise of the Palisades Plant Site Emergency Plan (SEP) and the
- ~mergency Implementing Procedures (EIPs) was conducted on May 19, 1987.
. :.The exercise tested the response of the licensee to a hypothet i ca 1
accident scenario, resulting in a major release of radioactive material to the environmen An attachment to this report describes the exer~ise scope and tibjectives and gives a sequence of events of the exercise scenari This was a utility-only exercise; however, the State of Michigan participated on an informal basis at the EOF~
2 General Observations Procedures This exercise was conducted in accordance with.10 CFR Part 50, Appendix E requirements using the Palisades Nuclear Generating Plant Emergency Plan and associated implementing procedure Coordination The licensee's response was generally coordinated, orderly and timel If these events had been real, the actions taken by the licensee would have been sufficient to permit State and local authorities to take appropriate actions to protect the public
.health and safet Observers Licensee observers monitored and critiqued this exercise along with four NRC observer Critique The licensee held a critique at the Palisades Plant on May 20, 198 The NRC critique followed immediately after the licensee's self critiqu Personnel who attended this joint meeting are listed in Section.
Specific Observations Control Room (CR)
The Shift Supervisor (SS) and his crew quickly responded to the first message at 0845, which reported a plane crash and damage to the security fenc The event was properly classified as an Alert and a PA announcement was made to the plant staff at approximately 085 The NRC observers concluded that the PA voice reception was unclear due to poor audibility; even immediately outside the CR in the adjoining hallwa Another voice was heard cutting in on the announcement which contributed to the poor receptio Assembly and accountability was quickly initiated when the siren sounde As the licensee was already aware that this siren.Could not be heard in the Support Building, a PA announcement was used in that area to assure adequate coverag To assure consistent as well as efficient notification to all plant buildings and outside areas, both the siren system and the PA system should be thoroughly sound tested and adjustments made where indicate The inspector learned from the licensee that some action is already underway on testing and improving the siren system and other mechanisms needed for emergency warning Until there is some evidence through drills and exercises of satisfactory reception of the emergency siren system, PA systems and other means to notify personnel in an emergency, this will be tracked as Open Item No. 50-255/87012-0 *
Security procedures were obtained quickly from the Security Identification Station and used by the shift personnel as they responded to security involved event The use of sound powered telephones between the SS 1s office and the TSC were well utilized and provided timely communication CR personnel used these telephones to provide several good suggestions to the TSC later in the scenari The transition of command and control from the initial Emergency Director, the SS, to the Site Emergency Director (SEO) in the TSC was accomplished efficiently and without undue dela Technical Support Center (TSC)
The SEO made his initial announcement that the TSC was activated and prepared to take charge of the emergency activities from the Control Room at 091 Just prior to this the Operations Support Group Leader in the TSC confirmed that communications were transferred to the TSC from the Control Roo Both actions were correctly taken in a proficient manner~ The TSC support groups appeared well prepared and cognizant of their responsibilitie With the plane crash at 0845 and the resin cask overflow taking place at about 0925 there was considerable activity in the TSC, particularly in the Health Physics (HP) Support Grou Still, knowing that the resin spill occurred as a result of a resin transfer, no one was observed in either the HP Support Group or in the OSC asking for the Container Checklist for Resin Liner from HP Procedure No. 6.1 This checklist would have had radiation survey information on it. Also, a radioactive material tag should have been attached to the simulated resin cas Determination of the curie content could also have been determined sooner if the players had asked about these sources of informatio When the Auxiliary Operator (AO) was dispatched to investigate the cause of the radiation alarm in the track alley area, he was not told where to meet the Radiation Safety Technician (RST).
This resulted in some unnecessary dela Information on the findings of the RST and the AO from the track alley area was slow in being communicated to the SS in the Control Room and to the TS The Dose Assessor could only produce on-line meteorology data from the plant 1s meteorology tower plus information from Weather Service International (WSI), since the dose assessment computer programs were based on gaseous releases, not a resin spill. A Security liaison was used throughout the exercis He functioned between the TSC and outlying areas where there was a security concern, at the break in the perimeter fence along the beach, at the portal*
monitor alarming in the Security Building, and at other security-related events including the ambulance response to the
- injured man.
- *
Good discussions, interactions and communications were observed between those at the TSC management table and the various TSC support group Management demonstrated good planning in considering what plant conditions could lead to an escalation of the emergency from the Alert statu The Site Area Emergency (SAE) was*
-declared based on the possibility of the resin spreading to sewers and the water supply of nearby towns using the Miscellaneous EAL categor Notifications to State and local counties within the EPZ were made properly and within the 15 minute requirement for both the A 1 ert and the SA Briefings by the SEO were frequent and meaningfu Status boards were adequately maintained with few exception Message flow as initiated by the clerical and adminis_tration group made a worthwhile contributio Through some communications error, a report of radiation levels of 500 mR/hour in the Support Building was forwarded to the TSC, which was cancelled a short time later. Meanwhile, the SEO announced no eating or drinking onsite because of those level This app-eared to be a Controller erro Operational Support Center (OSC)
The OSC was activated in a timely manner without any noticeable flaw The DSC Di rector wanted to be sure accountability was completed before deploying field teams as recommended by the TS The Radiation Protection Supervisor (RPS) authorized:the first team-of RSTs to receive 1 R/hour and provided dosimeters only to that leve When 900 mR/hour was measured at -the boric acid tank room (0935) adjacent to the track alley, the team retreated to the
-
stairwell for a 5-10 minute delay while dose histories were checke These dose histories should have been available in the OSC prior to dispatching the teams to avoid.a delay if greater radiation exposure were encountere Also, the first team did not have high range radiation monitoring instruments or respiratory protectio Not knowing the extent of the resin spill, a higher reading monitoring instrument (e.g., reading up to 50 R/hour) and higher range dosimeters should have been issued initially. There did not appear to be any input from maintenance support personnel in determining how to remove the resin contaminatio Air samples were not observed being taken in the track alley are However, at the exit meeting, a Controller confirmed that air samples were taken at the beac The OSC Director left the floor several times for briefings at the TS Each time he should have announced his leaving to the OSC staff and designated a temporary replacement for OSC Director until his retur Due to the simulation utilized, it was difficult to
. telJ if the area outside of the track alley was secured for contamination purpose (This is discussed further in Section 4.f.)
The RPS effectively organized and directed the in-plant teams and the field teams near the plant boundarie Communications between the field teams surveying along the beach with their respective control.points, namely the EOF and OSC, indicated that there may have been some duplication of effor The EOF arid OSC should have clarified which response facility was going to control the monitoring team The NRC observer concluded that the extent of. the contamination was never well define Onsite contamination levels ~easured background to 30 mR/hour on the hill above the construction shacks, while the OSC considered that the general area was 5-8 R/hou Iriitially, this 5-8 R/hour was considered to be 11window open 11 at contac Actually, it was 11window closed" at contac Beta-gamma contributi6ns were not determine After the sand was piled on top of the resin contaminated areas, no dose rate measurements were taken above the san Before action was taken to contain the resin contamination, the NRC observers felt that there was too much discussion and deliberation on.what approach to use to cover the resin and in trying to determine the extent of contaminatio Decisionmaking was slo Additional HP technicians from the nearby D. C. Cook Nuclear Plant were calle for early enough after the resin spill to provide needed supplemental monitoring capabilit Based on the above findings, the following items should be considered for improvement:
Basic radiation monitoring techniques with discussion of appropriate significances of 11open window, closed window" readings, plus the use of appropriate radiation monitoring instruments for emergency conditions should be re-emphasized in mini-drills and practtce session *
Better coordination and quicker decisionmaking should be emphasized in practice drills i~volving the OSC, the TSC, and the EO Approaches for handling either a resin spill or other non-gaseous radiation hazards should be emphasized in training and drill Medical Ori 11 The medical drill was observed at both the site and the Memorial Hospital, St. Joseph, Michiga Immediately after discovering the injured person, one of the RSTs contacted the OSC by radio to i~form them that the injured person had been found on the trackway near the roll-up door in the Auxiliary Buildin After this initial notification to the OSC, the two RSTs left the injured person and searched for a backboard on which to place hi Also during this
time, the RSTs appeared to be involved with other aspects of the resin spill. There were other times, also, when the injured person was left unattended. *No actions were taken to assist the injured person, except to give reassurances that help was comin W~en the ambulance arrived, approximately 16 minutes after the injured person was discovered, members of the security force escorted the ambulance to an area in front of track alle This location, while close to the victim, was also adjacent to the contaminated are Another 16 minutes elapsed while the ambulance attendants awaited protective clothing before they could begin examining the injured perso During this time, an RST taped the wheels of the gurney to prevent loose contamination from adhering to the wheel Pali sades Emergency Imp l el1'lentat ion Procedure (EIP), EI-14:
Medical Care/Treatment of Contaminated, Injured Personnel, Section 4.3, states that Radiation Safety Technicians should respond to an accident scene with the Emergency First Aid Kit, the Emergency Ambulance Kit and the Emergenc Decontamination Ki If only one technician is available, he should respond with the First Aid Kit and request assistance from the Control Roo During this exercise these kits were not brought to the accident scene until after the ambulance had arrive Procedure EI-14, Section 5.2.1, requires that preserving vital functions and providing emergency medical care takes precedence over contaminatio The NRC observer concluded that contamination concern took precedence in this exercis With all the expressed concern of the players, the victim 1s torso was never surveyed -
only the head wound and the left cheek as i dent ifi ed earlier by the Controlle Impingement of resin beads in the victim 1s face was possible since he was lying face down in the resin spil Approximately 51 minutes elapsed from the time the injured person was discovered, until the ambulance had left the site for the hospita This was much too long for trained responder Palisades Emergency Implementation Procedure, EI-3, 11Communications and Notifications, 11 requires that the notification of hospitals receiving contaminated injured victims should be performed using the Hospital Notification For This form was not used to notify the hospita The licensee Controller and the NRC observer had to go through normal egress portals at access contro Thus delayed, neither one could contribute to the medical drill at the hospital for some tim The injured person was already in the Emergency decontamination room when they arrive Either the ambulance.
should be held up until they arrive at the exit gate or another Controller should be assigned to the hospital to be in position\\
when the ambulance arrive Yellow Herculite was used to cover the
- ground from the ambulance to the examining room in addition to having this area roped off. A hospital representative was stationed at the outer entry way to this area, and requested proper
identification before allowing individuals to ente These were good examples of preparation and control of personnel in the emergency room are Step off pads were properly used in the examining room and contaminated site material was placed in the proper waste bag Waste containers were returned to the Palisades.sit Hospital personnel were properly attired in protective clothing and dosimetr Radiation level readings of the patient were taken by a Palisades RST and repeated to a nurse who documented the information. It should be noted that a large yellow plastic container was attached by a long tube to the drain of the table where the victim was lyin Liquid waste drained from the table into the containe However, when hospital personnel attempted to drain the liquid fro the table, the tube was not properly secured in the drain and liquid spilled onto the floo Greater care should be taken assuring that this equipment is properly secured and operable before being use Procedure EI-14, Sections 5.3.8 and 5.4.10, require that the SS and the Duty Health Physicist be briefed upon return to the plan Also, 5.4.11 requires that appropriate entries be made in the HP logboo These actions were not taken as observed by the NRC inspecto In summary, the medi,cal drill portion of this exercise was unsatisfactory.and will be tracked as an Open Item (50-255/87012-02).
The licensee should seriously examine their entire medical response syste This element of the exercise is designated as a reportable weakness and is further summarized in the enclosure to the cover letter to the license Reemphasis on training should be stressed for those individuals who would respond in a medical emergency onsit This capability should be demonstrated through mini-drills and other training to include the coordination, teamwork and interactions of all concerned to respond in a timely, professional manne EIP, EI-3 and EI-14 should be reevaluated to provide the most efficient means to*assure better coordination and success in a medical dril Emergency Operations Facility (EOF)
Briefings by the Emergency Director were well done on a period basis of approximately every half hou Due to the nature of this scenario., recovery aspects and projection of the damaging effects of the spread.of the radioactive contaminated resins beyond the owner controlled areas were significant items of concern from the early
identification of the proble The State of Michigan chose to participate in an unofficial capacity and served as a*communications link to local and State goveinmen The Michigan Department of State Police, Emergency Management Division and the Radiological Health Services Division of the Department of Public Health were represented and interacted with the EOF management from a separate location in an adjacent building, the Manor Hous This facet of the emergency response was meaningful and illustrated good coordination between the licensee and these two critical State agencie The exchange added to the realism of the joint effort, including a State decision made to cut off the South Haven Water Works drinking water intak The State contacted the Department of Energy (DOE) to get an aerial survey of the area to locate the resin path ih the wate The radiation safety monitoring teams from D. C. Cook were assigned areas to monito As listed in Section 4.c, the EOF had to assume some responsibility for the mixup, in which plant site and offsite teams were reporting radiation monitoring information to the EOF, rather than to the TSC or OS Although the scenario did not lend itself to conventional dose assessment, the HP Supervisor improvise He utilized radioactive inventories from the dose assessment code LADTAP, and scaled down the values to apply to the resin tank content This gave him an estimate of potential offsite doses due to inhalation, ingestion, and external radiation from activity released to the lake~
Accurate information on radiation levels from various distances and geographical locations as related to the resin spill was lacking at time From an observer's viewpoint it appeared that some radiation levels were given to represent an overall area in the direction of the resin spill, while others represented values within a few feet or near contac Good questioning by EOF and TSC HP support groups often, but not always, clarified the significance of these radiation levels.*
The EOF Director and his management support staff were intent on deescalating to an Aler In this pursuit they should have referred directly to the Table of EALs in either the Site Emergency Plan (SEP) or the Emergency Implementing Procedures (EIPs), rather than rely on subjective reasonin Guidance from NRC Headquarters specifies avoiding the emergency deescalation step, and instead, when there is assurance that the plant conditions have stabilized and the health and safety of the public is no longer in danger, change to a Recovery stag Of course, whatever courses of action are pursued, the State should agree since they have the decision on offsite actions affecting the publi Recovery plans were initiated by the EOF Director and EOF Officer by deciding on the team leaders for each supporting plant organization and the appointment of a Recovery Manage Tasks were designated for each group to pursu An outline of the main tasks and
subheadings were made up and distributed to the group leader Examples of specific steps included were additional decontamination, technical support, budget allocations, packaging of wastes, and actions to prevent recurrenc This represented a rather definitive approach to recovery/reentr In retrospect, real time should have been allocated to have a "round table 11 discussion with all.key recovery participants where each could present his input to the outline just describe The SEO from the TSC and at least two of his support managers should have attended such a sessio In summary, the recovery aspect was demonstrated sufficiently to indicate some preparation and plannin Exercise Scenario and Control This scenario was particularly different and challenging in centering around a resin spill outside the plant building It was unique from all others previously held by the licensee, which in general related to equipment failure or electri~al problem The exercise planners and the Emergency Planning Coordinator (EPC)
were surprised that until about 1045 the TSC and OSC staff were not aware that the cracked corn in the track alley outside the jammed roll-up door represented resi The Controller informed the initial RST responder However, the technicians apparently did not pass this information back to the OSC or TS To facilitate a more appropriate response, the NRC Team Leader when requested gave permission to the EPC to inform the OSC and TSC what the cracked corn represente Normal radiation hazard rope and radiation labels should have been used to cordon off the contaminated are This would have been more convincing and elicited greater respect to the hazard than what was substitute Several disclaimer signs could have been hung from the rope stating that this was for drill purposes onl Also, if an empty resin cask could have been positioned near the simulated spill, more realism would have been create These were two specific examples of lack of realism for this type of an emergenc In summary, some of the indecision and excessive 11 jaw-:-boning 11 was due to this unusual type of emergency and can be understood to a certain degre This exercise should stimulate concern for emergency responsibilities for those licensees with. radiation waste and HP organizational authority to get more directly involved in the respons. :.*Exit Interview The* inspection team he 1 d an exit interview the day after the exerci s*e on May 20, 1987, with the licensee representatives denoted in Section The NRC team leader discussed the scope and findings of the inspection and identified the medical drill as a probable exercise weaknes The
inspectors also discussed the probable content of the report to determine if the licensee considered that any of the information should be proprietar The licensee responded that none of the information should be proprietar Attachment:
Palisades Exercise Scope and Objectives and Narrative Summary 11 SCOPE AND OBJECTIVES SCOPE PALEX 87 is designed to meet exercise requirements specified in 10 CFR 50; Appendix E,Section I It will postulate events which would require activation of major portions of the site emergency plan and response by offsite authoritie The exercise will be utility onl There will be no participation from state or local authoritie The Joint Public Information Center will not be activate.2 OBJECTIVES The exercise will demonstrate each item listed under the following categories: Assessment and Classification Recognition of emergency conditions Timely classification of emergency conditions in accordance with emergency action levels Communication Initial notification within specified time constraints (state and local - 15 minutes, NRC - 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />) Subsequent notification in accordance with procedure (state, local, NRC) Notification and coordination with other organizations, as required (other utilities, contractors, fire or medical services} Provision of accurate and timely information to support news release activity Radiological Assessment and Control Calculation of dose projection based on sample results or monitor readings Performance of in-plant and offsite field surveys Objective deleted Trending of radiological data Formulation of appropriate protective action recommendations Contamination and exposure control MI1086-0006B-TP11-TP01 __
"' ___.,
t1
- ~
- ~ Emergency Response Facilities Activation, staffing and operation at appropriate classifications and within specified ~ime constraints Adequacy of emergency equipment and supplies Adequacy of emergency communication systems Access control Emergency Management Command and control with transfer of responsibilities from Control Room to Technical Support Center to Emergency Operations Facility Assembly and accountability within 30 minutes Coordination with State of Michigan emergency organization Mitigation of operational and radiological conditions Mobilization of emergency-teams Reentry and Recovery Assessment of damage and formulation of recovery plan Identification of constraints, requirements and organization to implement the plan
- Exercise Control Provision for maximum free play Accurate assessment of player performance MI1086-0006B-TP11-TP01 ;.
1 SEQUENCE OF EVENTS Scenario Time-0030 0000 0005 0015
- 0030 0040 Event Initial conditions - Normal full power Buses 13 and 14 crosstied; buses 77 and 78 crosstied Equipment out of service: Control Rod Drive 36, Air Blast Breaker 25R8, boric acid Pump A and the post-accident sampling monitor A resin tran~fer is in progres Alarms:
Control Rod Drive 26 seal leak off temperature and containment monitor RIA-1808.
PCS leak rate as of 0736 on 5/19/87: 0.6 gpm unidentified, 0.28 gpm identified, 0.88 gpm total Further historical data will be provided by Controlle.r if requeste Exercise begin A small plane crashes into the PM&HP buildin The north security fence is damage Damage assessment reveals that the plane was destroyed on impact; there. is no fir The plane was apparently unoccupied as no bodies are foun Security fence down nearb An alert is classified based on aircraft crash on facilit Accountability commence The Auxiliary Operators conducting the resin transfer have stopped the pump as the cask is almost ful They depart the scene when accountability begin The track alley door has been jammed open for several day Shortly after the departure of the Auxiliary Operators, the resin cask overflows due to depressurization of hose A resin spill is in progres Resin spill causes alarm of volume reduction system radiation monito By now, the TSC and OSC are staffe Word is received that the pilot of the plane had bailed out before the crash and has not been injure Resin flow stop T-100 has gone from 90% full to 5% ful It had been expected to fill the shipping liner after decreasing to RP0387-0220A-TP21-TP11
Scenario Time 0045 0049 0052 0055 0102 0130 20% ful Thus, 15% of tank volume has *pilled. r-100 surface dose rate was 68 R/hr when 60 to 100 Ci in 30 ft 3 of resi Severe winds strike plant. Berculite and spilled reains at transfer site are blown northwar Security building portals alar Security should notify the Control Room of conditio A RAD Technician dispatched to check radiological conditions slips and falls into the spilled resi Be sustains a head injury and is contaminate The injury is reported to the Control Roo An ambulance is calle RAD Technicians decontaminate the injured party to the extent possibl Magnitude of resin spill and subsequent spreading becoming clear. Radiation monitor readings and visual evidence indicate spread of contamination beyond security fence and possibly site boundar A site area emergency will be declared when dose levels are observed to be greater than 500 millirem per hour beyond site boundar EOF activated, if not yet don Ambulance arrives, either victim taken to ambulance* or escort provided to reach victi Control Room should no~ify hospital to prepare to receive and treat contaminated injur Extent of contamination determine They have been blown from original spill site north across plant and northward up beach beyond *site boundar Apparently resins have gotten into the lak Plant staff has reported to EO General Office Response Team arrives at EO Planning begins for cleanup of resin contamination. -Contaminated area is isolated and poste General Office EOF staff arrive Initial clean-up activity in progres Clean-up plan complete Portions will already have been implemente Full personnel mobilization will not be requeste Players will be expected to mobilize numbers and types of personnel dictated by extent and type of contaminatio Prog-ress will be judged by controllers with appropriate results reported to clean-up crew Some lake wasbup will occu Plant and EOF staff will be expected to administratively set up the mechanics of a full-scale cleanu These include contacts with RP0387-0220A-TP21-TP11
Scenario Time 0500 to 0600 Event
- companies, arrival times, waterborne contamination control, long-term monitoring progrui, et Exercise end Cleanup has been demonstrated adequately and long-term plan formulate RP0387-0220A-TP21-TP11 3