IR 05000289/1997002
| ML20138E018 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 04/24/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20138E016 | List: |
| References | |
| 50-289-97-02, 50-289-97-2, NUDOCS 9705010335 | |
| Download: ML20138E018 (29) | |
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U. S. NUCLEAR REGULATORY COMMISSION
REGION I
Docket No:
50-289 Report No:
50-289/97-02 Licensee:
GPU Nuclear i
Facility:
Three Mile Island Nuclear Generating Station
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Location:
P.O. Box 480 Middletown, PA 17057 Dates:
March 5-7,1997 Inspectors:
J. Laughlin, Emergency Preparedness Specialist, Region 1 N. McNamara, Emergency Preparedness Specialist, Region 1 D. Silk, Sr. Emergency Preparedness Specialist, Region I W. Maier, Emergency Preparedness Specialist, NRR l
S. Klementowicz, Health Physicist, NRR M. Evans, Sr. Resident inspector, Three Mile Island
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R. Struckmeyer, Sr. Radiation Specialist (Dosimetry), Region I l
Approved by:
Richard R. Keimig, Chief
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Emergency Preparedness and Safeguards Branch i
Division of Reactor Safety i
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9705010335 970424 l
PDR ADOCK 05000289 G
PDR j
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EXECUTIVE SUMMARY Three Mile Island Full-Participation Emergency Preparedness Exercise Evaluation Inspection Report 50-289/97-02 l
This inspection evaluated the licensee's emergency response capabilities demonstrated l
during its biennial full-participation emergency preparedness (EP) exercise. The inspectors l
observed emergency response facility (ERF) staffing, procedure implementation, l
effectiveness of mitigation actions, communications, command and control, emergency i
classification, offsite notifications, and protective action recommendation (PAR)
formulation. The inspectors also assessed licensee rsctivity pertaining to two open items that were identified in the previous exercise.
l The ERFs were generally staffed and activated in a prompt manner. The Site Area Emergency event classification was correct and timely. Offsite notifications were i
completed within 15 minutes. The performance of the_ Operations Support Center was excellent. The first PAR, based on plant conditions, was provided to the Commonwealth of Pennsylvania within the required 15 minutes of the general emergency (GE) declaration, and was appropriate.
Despite the above-stated observations, the licensee's overall performance was poor. The NRC inspection team identified four exercise weaknesses: 1) the ERO failed to recognize a GE when warranted by plant conditions; 2) the ERO staff incorrectly evaluated steam l
generator tube leakage; 3) the technical analysis of simulated accident conditions provided to ERO managers by the Technical Support Center staff was inadequate; and 4) the Emergency Operations Facility staff did not assess, and discuss with offsite officials, the need for a PAR for residents outside the 10-mile emergency planning zone when dose projections appeared to indicate that protective action guidelines would be exceeded.
Additionally, due to the incorrect radiological data provided to the field monitoring teams, resulting from simulator malfunctions and controller actions, the inspectors were unable to determine if the exercise weakness identified during the previous exercise, related to the assessment of offsite radiological consequences was corrected, and it will remain open.
Exercise weaknesses 1 and 4 are being considered for enforcement action since they may constitute violations of the licensee's Emergency Plan and its implementing procedures.
The licensee's post-exercise critique was adequate, but with some shortcomings. It did not identify weaknesses 3 and 4 above. Also, it did not address whether the exercise objectives had been met, and tended to characterize personnel performance problems as procedural and/or simulation deficiencies, and did not point out any issues of special concern.
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Report Details l
IV. Plant Support P3 EP Procedures and Documentation l
a.
Inspection Scope (82301)
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The inspectors reviewed the licensee's revised protective action recommendation i
(PAR) logic diagram contained in emergency plan implementing procedures l
EPIP-TMI.02, " Emergency Direction," and EPIP-TMI.27, " Emergency Operations i
Facility," to determine if the diagram was consistent with the licensee's emergency l
action levels (EALs).
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Observations. Findinas and Conclusions
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The inspectors found that, in the basis for EAL G3.1 (Security Event in a Vital
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Area), the PAR conflicted with the PAR guidance in the revised logic diagram. The revised diagram specified a directionally uniform PAR that is independent of wind i
direction, while the basis for EAL G3.1 specified a PAR that would evacuate the risk
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population in the downwind direction only. The inspectors determined that EAL G3.1 could result in confusion on the part of emergency managers in the l
Issuance of a PAR.
The licensee stated that it had failed to update the existing EAL basis for
consistency with the revised PAR methodology, and that an appropriate revision I
would be made.
P4 Staff Knowledge and Performance a.
Exercise Evaluation Scope (82301)
During this inspection, the inspectors observed and evaluated the licensee's biennial full-participation, emergency preparedness exercise in the emergency control center (ECC) simulator, technical support center (TSC), operations support center (OSC),
emergency operations facility (EOF), and the joint information center (JIC). The inspectors assessed liconsee recognition of abnormal plant conditions, classification of emergency conditions, notification of offsite agencies, development of PARS, command and control, communications, and the overallimplementation of the Emergency Plan. In addition, the inspectors attended the licensee's post-exercise critique to evaluate the licensee's self-assessment of the exercise.
b.
Emeroency Response Facility (ERF) Observations and Critiagg b.1 Emeroency Control Center (ECC)
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The Emergency Response Organization (ERO) staffed the ECC in a timely manner.
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The Shift Supervisor Emergency Director correctly classified the Site Area Emergency (SAE) and the notification of offsite agencies of this event was accurate
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and within the required 15 minutes.
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The ERO Emergency Director (ED) showed strong interest in the radiological sefety
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of onsite personnel. He took early action, based on the recommendations of his
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subordinates, to evacuate non-essential personnel to a location outside of the l
radioactive plume. He also prompted a discussion with the Radiological Assessment
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Coordinator (RAC) about administering a thyroid blocking agent to repair teams entering radiologically hazardous areas.
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However, the overall command and control demonstrated by the ED was weak. For l
example, the Operations Coordinator (OC) repeatedly prompted him to provide event l
briefings to the onsite facilities. Also, when he declared a General Emergency (GE)
l condition, he sought confirmation from the exercise controller that this was the j
proper action.
l The OC exhibited excellent command and control in directing the actions of the
operations crew. He stayed informed of plant conditions and was very proactive in l
directing mitigation strategies and corrective actions. He also provided effective management support to the ED.
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The operations crew, along with the TSC staff, incorrectly assessed steam i
generator tube leakage (primary-to-secondary leakage). The crew calculated a i
primary-to-secondary leak-rate while the steam generator water inventory was heating up, which gave the erroneous indication of a substantial tube leak. The crew estimated the leak-rate to be about 100 gallons per minute (gpm) when the
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actual leak-rate was very small, about 2 gallons per hour.
The ED directed the TSC staff to verify the 100 gpm leak-rate, which they did (in error), but he did not question the basis for that validation. The ED declared a i
GE due to the failure of all three fission product barriers based on the erroneously
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calculated primary-to-secondary leak-rate, which indicated that the containment barrier had been breached. (The reactor coolant system and fuel clad barriers had l
been breached previously.) The Emergency Support Director (ESD), located in the EOF, concurred with this erroneous declaration. However, a licensee exercise l
controller prevented the incorrect GE declaration, to maintain the integrity of the j
scenario timeline in order to accomplish all of the offsite emergency planning
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objectives.
The incorrect primary-to-secondary leak-rate calculation revealed a shortcoming in the ERO's ability to analyze plant conditions. This issue is discussed in more detail in Section b.3, " Technical Support Center."
Later in the exercise, the ED, in consultation with the ESD, failed to recognize a condition in which all three fission product barriers were breached as one that required the declaration of a GE. As a result of the simulated loss of coolant j
accident, the ED and his staff recognized that plant pressure and temperature
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conditions were indicative of failed fuel cladding and, thus, two of the three fission product barriers were breached. Later, when the third fission product barrier j
(containment) was breached, due to a coolant leak from the decay heat removal j
system in the auxiliary building, the plant pressure and temperature conditions had
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changed and were no longer in the range where fuel damage could be expected to i
occur and based upon that, the ED did not declare a GE. However, the ED
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apparently failed to recall that the fuel clad barrier had been breached earlier.
Therefore, the ED failed to recognize that three breached barriers existed and a GE declaration was required. The lack of specific procedural guidance contributed to l
the missed classification, but performance lapses by the ED and ESD were primarily
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responsible. After 21 minutes had elapsed from the time the third barrier was lost, an exercise controller prompted the ED to make the GE declaration. This failure to recognize and classify the GE condition is assessed as an exercise weakness (eel l
50-289/97-02-01).
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The licensee's Emergency Plan, Section 5.1.3.1, " Direction and Coordination,"
states in part, that "The Emergency Director is vested with certain authority and responsibility that shall not be delegated to a subordinate. Included are:.. 5.
Classification of an emergency event." Emergency Plan implementing Procedure
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(EPlP) TMI.01, " Emergency Classification and Basis," item G4.2, requires the declaration of a GE for the " Loss of 2 of 3 fission product barriers with a potential j
loss of 3rd." Because the ED could not utilize emergency action level G4.2 to l
classify a GE when this declaration was warranted due to the simulated loss of the I
three fission product barriers, this is an apparent violation of the licensee's Emergency Plan.
Communications among the onsite ERFs and between the ED and ESD were very i -
good. Dedicated communicators monitored the inter-facility circuits and quickly communicated all messages. They also maintained logs for these circuits, and tracked information requests to ensure a response.
b.2 Dose Assessment in the ECC Shortly after the SAE declaration, the Group Radiological Controls Supervisor arrived at the ECC and placed the dose assessment process into operation. He immediately
activated the automated dose assessment computer to obtain an initial dose assessment and requested that the OSC dispatch a field monitoring team (FMT) to a downwind location close to the plant to perform radiation surveys. He conferred with the ED on the status of plant systems and calculated dose projections. They discussed the possibility of a GE declaration based on the potential degradation of plant and/or radiological conditions. The ED did not think that a GE was warranted based on the plant conditions, and requested that additional radiological monitoring and assessment be performed.
The RAC arrived within 30 minutes of the SAE declaration and, after receiving a turnover, took charge of the dose assessment area. Initially, there appeared to be a significant amount of confusion with the dose assessment team due to poorly defined duties for team members. Also, the work area was very congested and noisy. Team members using telephones had difficulty communicating and hearing information during their conversations.
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The RAC directed his staff to perform dose projection calculations based on existing l
plant conditions and projected "what if" conditions. He had frequent conversations with the operations crew concerning plant conditions and effluent radiation monitor readings which were used for dose projection calculations.
l The FMT data were provided by onsite and offsite teams. Communications between the RAC and the FMTs were good. The RAC positioned the FMTs downwind of the release so they could measure the associated radiation levels.
However, the RAC was unable to obtain correct radiological data from the FMTs i
due to simulator problems which resulted in an incorrectly low radiological release j
rate from the plant. This problem was compounded when an exercise controller j
requested that the release rate be artificially increased by a factor of 100, to provide
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a release of sufficient magnitude such that " realistic" radiation levels could be detected by the FMTs. Due to other circumstances, this adjustment did not correct
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the low radiation levels detected in the field (which indicated background levels),
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but did result in an erroneously high source term amount being used for dose l
projection calculations. Therefore, the incorrectly high dose projection calculations could not be substantiated by the erroneously low field readings. Additionally, the data from the Reuter-Stokes (R-S) area radiation monitors around the site were incorrectly low. This inconsistency caused confusion among the dose assessment
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staff. The RAC, faced with conflicting data, questioned an exercise controller about j
the validity of the data, and whether back-up data was available if the simulator l
was in error. The controller acknowledged that there was a problem with the
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simulator data, but that no backup data was available.
The inspectors observed effective coordination between the RAC and the Radiological Controls Coordinator (RCC) in the OSC concerning the radiological safety of radiation survey and repair teams. The RAC discussed the need for radiation dose extensions with the ED in order to complete important plant repairs.
In addition, the RAC authorized the administration of potassium iodide (Kl) for a contaminated worker, provided that the uptake of radioiodine would result in a thyroid committed dose equivalent (CDE) of greater than or equal to 25 rem and
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that the Kl was approved by the GPUN Medical Director. The ED concurred with the RAC's authorization to administer Kl to the worker.
The inspectors reviewed the licensee's procedure EPIP-COM.44, " Thyroid Blocking," and found that it directed the RAC to perform an assessment of a worker's dose prior to authorizing the administration of KI, but the procedure did not contain any guidance on how to perform the assessment. The inspector discussed this lack of procedural guidance with the licensee who agreed to review the procedure and make changes, as appropriate.
f Late in the exercise, the dose assessment staff calculated a projected dose of approximately 54 rem CDE to the thyroid at a distance of 10 miles from the plant.
This dose projection was based on plant radiation monitor readings, effluent flow
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rates and an overly conservative estimated source term. Because of problems with l
the simulator, the RAC was not able to obtain correct radiation readings from the t
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i FMTs or the R-S monitors to validate the dose projections. The RAC discussed the
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large calculated dose with the ED to determine if the original PAR, which
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recommended an evacuation out to 5 miles, should be expanded. The ED doubted l
the validity of the dose projections and directed the RAC to verify the calculation.
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The RAC initially responded that the inputs to the calculation were valid, however,
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he had no independent FMT data to verify it. The RAC discussed the situation with l
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l his staff and with the Environmental Assessment Coordinator (EAC) in the EOF.
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There was confusion as to the appropriate plan of action since the FMT data and/or l
R-S data did not support the large calculated dose. The exercise was terminated l
before additional assessment could be performed. Based on the dose projections,
I which were communicated to Commonwealth of Pennsylvania personnel, the
licensee should have assessed the need to extend the PAR beyond the 10-mile emergency planning zone (EPZ). This action was not done, and its omission was
considered by the NRC to be an exercise weakness (See Section b.5).
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Overall, the inspectors noted effective coordination, teamwork, and communication amore dose assessment personnel and the ED concerning radiological conditions.
The RAC demonstrated good overall control of the dose assessment area, direction
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of the FMTs, knowledge of plant systems and their status during the exercise. He
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I had frequent interactions with his staff, the ED, and the operating crew concerning radiological conditions, both onsite and offsite. He exhibited a questioning attitude
and continually anticipated the next course of action. Dose assessment team
members effectively performed their job functions by providing the RAC with updated meteorological data and dose projection calculations.
An exercise weakness from the April,1995 exercise concerning the licensee's ability to rapidly assess and predict potential offsite radiological consequences was
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reviewed. The licensee's corrective actions for this weakness could not be assessed due to simulator problems, which resulted in the generation of incorrect radiological data. That weakness will remain open.
b.3 Technical Sucoort Center (TSC)
" The TSC was staffed and activated in a timely manner. The TSC staff was generally aware of plant conditions and provided some good technical support
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including the classification of core damage.
Although the TSC Coordinator (TSCC) exhibited adequate command and control following the declaration of the GE at about 8:45 p.m., prior to that time he did not.
For example, during facility briefings, he did not always have the full attention of his j
staff, and did not speak clearly enough to be understood by all of his staff. The TSC staff effort lacked coordination, which resulted in staff members independently t
working on the same issues and analysis results not being communicated to the j
TSCC in a timely fashion. Additionally, the TSCC instructed one member of his i
j staff to refrain from the review of EALs for potential event classification upgrades, since in his opinion, that was not the responsibility of the TSC.
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The staff engineers did not effectively process available data to make accurate i
assessments of plant conditions. For example: they did not accurately assess primary-to-secondary leakage; they did not accurately identify the location of the i
break in the decay heat removal piping in the auxiliary building; and they did not-i
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recognize that the decay heat removal piping break combined with the failure of valves DH-V-1, DH-V-2 and DH-V-3 in the open position was a breach of the
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containment fission product barrier. Overall, the technical analysis of simulated accident conditions provided to the ECC by the TSC staff was inadequate, and is assessed as an exercise weakness (IFl 50-289/97-02-02).
The ERO staff did not demonstrate that it could accurately determine a primary-to-secondary leak-rate with the assessment tools available to them and early in the i
exercise for about 75 minutes, the TSC staff misinterpreted total RCS leak-rate due
to a loss of coolant accident, as primary-to-secondary leakage. However, once they
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identified this error, they were still unable to accurately calculate the primary-to-
secondary leak-rate. As a result, when asked by the ED to validate the incorrect I
' primary-to-secondary leak-rate (100 gpm) calculated by the ECC staff, they reported that an approximate 100 gpm leak-rate appeared correct, instead of reporting that
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the available data revealed a leak-rate of approximately 100 gpm with a potential error of 100%. This inappropriate validation appeared to cause the ED not to seek additional verification.
During the previous evaluated exercise in April,1995, the TSC staff was unable to correlate the available data, including radiation levels, to reliably determine the
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existence of a primary-to-secondary leak (which did exist). In that instance, the
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TSC engineers had difficulty diagnosing this leakage even after its existence was
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apparent to personnel at the other ERFs. The incorrect analysis of primary-to-
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secondary leakage during this exercise is assessed as an exercise weakness (IFl 50-289/97-02-03).
b.4 Ooerations Suonort Center (OSC)
The OSC was staffed and activated within 20 minutes of the SAE declaration. All primary positions were initially filled with on-shift personnel until the arrival of the ERO. The on-shift chemistry coordinator was not familiar with his assigned duties and asked the on-shift OSC Coordinator (OSCC) for assistance. This was a minor distraction for the on-shift OSCC but did not impact facility activation.
Logs and status boards were well-maintained and in-plant repair teams were effectively tracked. Job priorities were set, tracked, and adjusted when plant conditions changed. The OSCC exhibited excellent command and control. He was knowledgeable and proactive in utilizing his managers to assist him in making decisions. The inspectors noted several good discussions between the OSCC and
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the shift foreman for developing plans to address potential problems and finding l
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alternative routes for repair teams in order to keep radiation doses as low as reasonably achievable. The RCC adequately performed his assigned duties.
However, the inspector observed that the RCC was hesitant when making decisions l
and providing support to the OSCC and health physics staff.
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The inspectors observed the activities of five maintenance teams and one chemistry
team. The emergency maintenance coordinator (EMC) briefed the teams and ensured that a health physics technician accompanied each one. The repair and in-
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plant investigation teams appeared knowledgeable, professional and captble of performing their assigned tasks. Chemistry samples were actually drawn and j
analyzed.
One team was required to enter a high radiation area in order to close the DH-V-3
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valve. This three-person team donned anti-contamination clothing and wore
respirators. However, team deployment was delayed for about 50 minutes while
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the RCC waited for the ED's approval to extend the radiation dose limits of team members. 'Also, a technician had difficulty operating the computer to reset the digital alarm dosimeters for the team. These delays presented potential heat exhaustion problems for the team since the team members were dressed out.
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Overall, the performance in the OSC was very good.
b.5 Emeroency Operations Facility (EOF)
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The pagers for the offsite ERO actuated at 4:55 p.m. following the SAE declaration at 4:48 p.m. The inspectors noted that the one-hour responders arrived at the EOF
by 5:42 p.m. so the EOF was staffed and activated in a timely manner. However,
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the inspectors did not observe the ESD announce the activation of the facility.
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Shortly after the ESD arrived, he inforrned the inspectors that, while driving to the EOF, he contacted the ECC via cellular telephone and was briefed on the simulated accident. The inspectors considered this to be a good initiative.
Facility access was controlled at all times. A simulated media representative attempted to gain access to the EOF but was stopped and redirected by security
personnel. Thus, the licensee addressed an area for improvement concerning EOF access control that was identified in the previous exercise.
Overall, ESD command and control was adequate. Even though noise levels were
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kept at a minimum, the inspectors observed that the EOF staff exhibited a casual attitude and that there were numerous conversations among the staff which were unrelated to the exercise. Dissemination of information in the EOF could have been
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improved. The inspectors noted regular briefings and status board updates, but the information was often cryptic. The ESD held regular meetings with the EOF group j
leaders to review plant conditions. However, the discussions emphasized
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anticipation of emergency escalation instead of mitigation strategy development.
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The leaders also regularly reviewed Exhibit 1E of EPIP-TMI.27, " Emergency
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Operatiuns Facility," which is a flowchart to assess conditions that can lead to a GE
declaration.. However, the EOF staff also failed to recognize the loss of the third i
fission product barrier when the leak occurred in the decay heat removal system l
outdde of containment, and thus did not recommend a GE declaration to the ED.
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Following the controller-prompted GE declaration, the EOF notified offsite agencies.
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in a timely manner and provided the appropriate initial PAR to evacuate residents I
within a five-mile radius of the plant. Later in the exercise, the licensee decided to upgrade the PAR to evacuate the entire 10-mile EPZ, based upon high dose projection calculations. These calculations projected a 54 rem CDE thyroid dose at
10 miles. However, the licensee did not assess the need for a PAR for residents beyond the 10-mile EPZ. Repiesentatives from the Commonwealth of Pennsylvania
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had introduced this topic to the EOF staff but the staff deferred the issue to the Commonwealth. The licensee was hesitant to consider a PAR beyond 10 miles because of the lack of FMT data to validate the dose projection calculations and
because its dose projection model did not extend beyond 10 miles. The inspectors considered the licensee's failure to assess, and discuss with Commonwealth officials, the need for a PAR beyond the 10-mile EPZ, when dose projection
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calculations appeared to indicate that protective action guidelines would be'
exceeded, as an exercise weakness (eel 50-289/97-02-04).
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i The Code of Federal Regulations,10 CFR 50.47(b)(10), states, "a range of
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protective action has been developed for the plume exposure pathway EPZ for l
emergency workers and the public. Guidelines for the choice of protective actions l
during an emergency, consistent with Federal guidance, are developed and in place, and protective actions for the ingestion exposure pathway EPZ appropriate to the locale have been developed." NUREG-0654/ FEMA-REP-1, " Criteria for Preparation and Evaluation of Radiological Emergency Response Plans and Preparedness in Support of Nuclear Power Plants," (a guideline to which the licensee has committed)
Section I.D.2, " Emergency Planning Zones," states "On the other hand, for the worst possible accidents, protective actions would need to be taken outside the planning zones" (10 miles for the plume exposure pathway) and Section 1.D.2.d states, " detailed planning within 10 miles would provide a substantial base for expansion of response efforts in the event that this proved necessary." The-licensee's Emergency Plan, Section 6.5.1, states in part, "The Emergency Support Director / Emergency Director shall be prepared to provide protective action recommendations, as appropriate.... Recommendations are developed when it is apparent that a release is possible or underway and dose projections indicate protective actions may be required for the public and within approximately 15 minutes of the declaration of a General Emergency." The licensee failed to assess
. the need for a PAR beyond the 10-mile EPZ when dose projection calculations appeared to indicate that protective action guidelines would be exceeded at that distance, this is an apparent violation.
When reviewing the dose projection calculations that were performed at the EOF, the inspectors observed that the licensee was making unrealistic and overly conservative assumptions sbout the amount of iodine being released to the environment. Following the fuel cladding failure, the RCS iodine concentration l
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would be diluted due to about three hours of emergency core cooling injection.
j When the leak cccurred in the auxiliary building, the RCS coolant was at a relatively
l low temperature, and in conjunction with the cool auxiliary building, would have i
resulted in minimal iodine coming out of solution to become airborne. Also, some of
the iodine that did become airborne would plate out (settle) on the surfaces of the equipment and structures in the auxiliary building. Finally, the remaining airborne
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iodine would have to go through charcoal filters (designed to adsorb iodine) before
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i escaping to the environment. Therefore, the 20% ratio of iodine to noble gas release that was assumed by the licensee was excessive. The inspectors recognized that the simulator problems (lack of reliable radiation monitoring' system l
readings and no detectable radiation by the FMTs) complicated the task for dose
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assessment personnel. However, the extremely high ratio of iodine to noble gas
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concentration should have been questioned by dose assessment personnel.
i b.S Joint Information Center UIC)
j The JIC, located in the same building as the EOF, provided good accommodations for the news media and utility public information personnel, and for state / federal governments representatives. The licensee news briefings were conducted by competent staff members who responded to questions from mock news media
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representatives. Rumor control and media monitoring functions were also conducted in the facility. Six news releases were issued during the exercise. There
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- was one rather lengthy (three-hour) interlude between news releases containing information on simulated accident status. However, the inspectors concluded that all public information objectives were adequately demonstrated, b.6 Exercise Conduct
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The inspectors noted excessive interaction between exercise controllers and players during the exercise. There was at least one instance of improper prompting of a player by a controller. One ECC controller prompted the ED by questioning him concerning his responsibilities for offsite notifications and PAR formulation. The
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question was asked after the GE declaration when the ED filled out the PAR section of the initial Notification Form. The formulation of PARS is the responsibility of the
ESD. This prompting had no impact on exercise conduct but was nonetheless i
inappropriate.
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The inspection team leader pointed out at the March 7,1997 exit meeting that there should be no controllerf ayer interaction except that which is necessary to l
maintain the integrity of the scenario timeline or prevent an unsafe condition.
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b.7 Licensee Exercise Critiaue immediately following the exercise, the licensee began its critique process. Players and controllers assembled in their assigned facilities and conducted a critique of their exercise performance. These findings were collected and presented to the NRC on March 7,199,
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The NRC inspection team assessed this formal critique as adequate, but it had several shortcomings. It did not identify two of the four NRC weaknesses (i.e., inadequate technical assessment by the TSC, and no assessment of the need for a PAR beyond the 10-mile EPZ). Additionally, the critique did not address whether the exercise objectives had been met, and it tended to characterize personnel performance problems as procedural and/or simulation deficiencies. The critique characterized items as strengths and areas for improvement, but did not i
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highlight any items for heightened attention which would warrant the same concern
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as an NRC exercise weakness.
c.
Overall Exercise Conclusions
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The licensee generally staffed and activated the ERFs in a prompt manner. The Shift Supervisor Emergency Director accurately classified the SAE, and the notification of offsite agencies was timely. The OC exhibited excellent command and control of the operations crew and exercised strong oversight of mitigation
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strategies. The performance of the OSC staff was very good. The OSCC
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demonstrated excellent command and control, and the teamwork of his staff was
commendable. The first PAR, based on plant conditions, was provided to the Commonwealth of Pennsylvania within the required 15 minutes of the GE declaration, and was appropriate.
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Overall, the performance of the ECC staff was weak. The ED failed to classify the GE condition, which is assessed as an exercise weakness and is an apparent violation (eel 50-289/97-02-01). The operations crew's erroneous calculation of
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primary-to-secondary leak-rate showed a deficiency in the analysis of plant
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conditions. The command and control demonstrated by the facility managers was
mixed, with that shown by the ED being weak. Onsite protective actions were timely and proper. Offsite notifications and communications were performed well, c
The dose assessment staff generally performed well. The RAC demonstrated good
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control of this area, and team members effectively performed their jobs. However,
the RAC could not validate the unusually high dose projection calculations with field data due to simulator problems and controller actions. This caused much confusion
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among the dose assessment staff.
Overall, the technical analysis of simulated accident conditions provided to the ECC by the TSC staff was inadequate, and is assessed as an exercise weakness i
(IFl 50-289/97-02-02). Also, the ERO staff did not demonstrate that they could
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accurately determine steam generator tube leakage. There was a similar issue during the last exercise. This inability of the ERO staff to adequately determine steam generator tube leakage is assessed as an exercise weakness (IFl 50-289/97-02-03).
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1 The overall performance of the EOF staff is assessed as poor. The staff failed to recognize conditions requiring the GE declaration and that iodine levels from dose projection calculations were excessive. They also failed to assess the need for a PAR for residents outside the 10-mile EPZ, which is considered an exercise weakness and is an apparent violation (eel 50-289/97-02 04).
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The licensee's post exercise critique was adequate, with some shortcomings. It did not identify weaknesses 2 and 4 above. Also, it did not address whether the exercise objectives had been met, and tended to characterize personnel J
performance problems as procedural and/or simulation deficiencies, and did not point out any issues of special concern.
P8 Miscellaneous EP issues P8.1 (Open) Weakness Observed Durina the April 12.1995 Full-oarticioation Exercise:
Weak Ability to Rapidiv Assess and Reliably Predict Potential Offsite Radioloaical
Conseauences The inspection team reviewed this item during this inspection. However, due to the incorrect radiological data provided to the FMTs, resulting from simulator
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malfunctions and controller actions, the RAC could not obtcin field data to verify the dose projection calculations. Therefore, the inspectors were unable to determine if I
this exercise weakness was corrected and it will remain ope" P8.2 (Ocen) Unresolved item (URI 50-289/95-05-01): PAR Loaic Methodoloav Not Conformina With Federal Guidance I
it was identified during Inspection 95-05 that the licensee's PAR logic diagram methodology did not appear to conform with Federal guidance, in that it relied on evacuation time estimates and release duration, without consideration of radiation doses that could be received.
l The inspection team reviewed this item during this inspection. The licensee revised its PAR logic diagram in a recent change to the emergency plan implementing procedures. However, due to the simulator malfunctions and controller actions which affected the dose assessment area and resulting PARS during this exercise, the team concluded that additional NRC review was necessary, and this item will remain open.
P8.3 Updated Final Safety Analysis Report (UFSAR) Review A recent discovery of a licensee operating its facility in a manner contrary to the UFSAR description highlighted the need for a special focused review that compares
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plant practices, procedures, and/or parameters to the UFSAR or the emergency plan. During this exercise, the inspectors observed the licensee's compliance with the emergency plan regarding ERO structure related to the elimination of the on-shift Radiological Controls Coordinator position, and facility activation and usage in relation to the new TSC. No discrepancies were noted.
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P8.4 In-Office Review of Licensee Procedure Chanaes An in-office review of revisions to the emergency plan and its implementing procedures submitted by the licensee was completed. A list of the specific revisions reviewed are included in Attachment 1 to this report. Based on the
!!censee's determination that the changes do not decrease the overall effectiveness of the emergency plan, and that it continues to meet the standards of 10 CFR 50.47(b) and the requirements of Appendix E to Part 50, NRC approval is not required for those changes. Implementation of those changes will be subject to inspection in the future.
V. Manacement Meetinas X1 Exit Meeting The inspector presented the inspection results to members of licensee management at the conclusion of the inspection on March 7,1997. The licensee was informed of the following:
e The NRC inspection team identified four exercise weaknesses.
e The weakness from the April,1995 exercise was reviewed, but will remain open.
e The unresolved item from the last exercise, concerning PAR logic methodology not conforming to federal guidance, will remain open.
e The exercise formal critique was adequate, with several shortcomings, e
Overall exercise performance was indeterminate, pending NRC regional management review.
The licensee acknowledged the inspection findings.
A formal exit meeting was conducted on March 17,199'7, at the Three Mile Island Training Center, which was open for public observation. The NRC inspection team leader presented the inspection findings to Mr. A. Rone and other members of the GPU Nuclear staff. The licensee agreed with the NRC assessment of the March 5,1997 exercise, including the four exercise weaknesses. At that meeting, Mr. Rone and the GPUN staff indicated that
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they viewed the ERO's weak performance as an anomaly. While the NRC agrees that i
performance during this exercise reflected a significant decline, we are not yet ready to conclude that there are not some underlying training and program management issues that affected licensee performance. Mr. Rone presented the licensee's planned corrective l
actions and committed to performing a remedial exercise by May 15,1997.
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PARTIAL LIST OF PERSONS CONTACTED Licensee N. Brown, Lead Emergency Planner D. Ethridge, Acting Director, Radiological Controls / Occupational Safety
J. Grisewood, Emergency Preparedness (EP) Manager L. Karinch, Media Relations Representative A. Knoche, Senior Emergency Planner A. Miller, Licensing Engineer J. Moore, Nuclear Safety Compliance Committee M. Ross, Acting Director, TMl G. Skillman, Director, Configuration Control J. Wetmore, Manager, Regulatory Affairs J. Whitehead, Senior Emergency Planner Commonwealth of Pennsvivania S. Maingi, Nuclear Engineer, Bureau of Radiation Protection HEC R. Keimig, Chief, Emergency Preparedness and Safeguards Branch INSPECTION PROCEDURES USED
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l 82301: Evaluation of Exercises for Power Reactors 82302: Review of Exercise Objectives and Scenarios for Power Reactors ITEMS OPENED, CLOSED, AND DISCUSSED l
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50-289/97-02-01 eel failure to recognize and classify a GE 50-289/97-02-02 IFl inadequate technical analysis by TSC steff l
50-289/97-02-03 IFl incorrect analysis of steam generator tube ieakage l
50-289/97-02-04 eel failure to assess need for PAR beyond 10-mile EPZ Closed
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None Discussed 50-289/95-05-01 URI PAR logic methodology not conforming with federal
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guidance 50-289/95-05 xx Weakness inadequate off-site dose assessment and projection
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i LIST OF ACRONYMS USED l
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CDE Committed Dose Equivalent
l CFR Code of Federal Regulations EAC Environmental Assessment Coordinator
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EAL Emergency Action Level
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ECC Emergency Control Center l
ED Emergency Director eel Escalated Enforcement item EMC Emergency Maintenance Coordinator l
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EOF Emergency Operations Facility l
EP Emergency Preparedness EPIP Emergency Plan Implementing Procedure EPZ Emergency Planning Zone ERF Emergency Response Facility
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ERO Emergency Response Organization
ESD Emergency Support Director l
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FMT Field Monitoring Team GE General Emergency GPM Gallons Per Minute l
IFl Inspector Follow-up ltem
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JIC Joint Information Center Kl Potassium lodide
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NRC Nuclear Regulatory Commission l
OC Operations Coordinator OSC Operations Sucaort Center OSCC OSC Coordinaior PAR Protective Action Recommendation RAC Radiological Assessment Coordinator RCC Radiological Controls Coordinator RCS Reactor Coolant System R-S Reuter-Stokes SAE Site Area Emergency SS Shift Supervisor l
TSC Technical Support Center l
TSCC TSC Coordinator UFSAR Updated Final Safety Analysis Report
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URI Unresolved item i
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EMERGENCY RESPONSE PROCEDURES REVIEWED
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Document Document Title Revision (s)
1000-PLN-13OO.01 Emergency Plan
EPIP-TMI.02 Emergency Direction
EPIP-TMI.03 Emergency Notifications and Call Outs
EPIP-TMI.05 Communications and Record Keeping
i EPIP-TMI.06 Additional Assistance and Notification
i EPIP-TMI.07 Activation of the RAC
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j EPIP-TMI.10 Onsite/Offsite Radiological /
Environmental Monitoring
l EPIP-TMI.19 Emergency Dosimetry / Security Badge issuance
EPIP-TMI.27 Emergency Operations Facility
EPIP-TMI.28 Activation of the Technical Support J
Center
EPIP-TMI.29 OSC Operations
EPIP-TMI.36 Emergency Assembly and Site Evacuation
TEP-ADM-13OO.01 Maintaining Emergency Preparedness
TEP-ADM-13OO.02 Emergency Preparedness Training
TEP-ADM-13OO.05 Emergency Equipment Readiness
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ENCLOSURE 2
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Planning
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March 17,-1997 i
by Art Rone Director Nuclear Safety & Technical Services b
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INTRODUCTlON
GPU Nuclehr agrees with the NRC's i
assessment of-the March 5 exercise i
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- Emergency Preparedness remains at j
a high state of readiness at TMI
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- We are committed to taking prompt corrective action including holding a remedial exercise t
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NEAR-TERM ACTIONS r
Root Cause Analysis I
-Forming an expe'rt team to look at:
- Training
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- Simulator issues
- Exercise controller actions
- Exercise critique process
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- Staff changes.in emergency preparedness organizations and j
emergency response organization
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NEAR-TERM ACTIONS (continued)
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Enhanced Training
- Train staff.to handle conflicting information,
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validate data, and understand basis for Emergency j
Action Levels
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- Coaching drills for personnel at all emergency
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response centers with a focus on communications
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- Training on when and how to evaluate Protective Action Recommendations (PAR) beyond the 10-t mile Em~ergency Planning ~ Zone.
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- Trai'ning for Technical Su'pport Center personnel j
on Center functions and. expectations.
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l NEAR-TERM ACTIONS (continued)
- Technical Support Center-Staffing i
Assessment
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- Ensure effective allocation of technical I
personnel among the emergency response centers j
- Tech' Support personnel will be trained as teams on any changes ~that result from this
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NEAR-TERM ACTIONS i
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- Primary-to-secondary leak rate calculation method evaluation
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Contact other B&W plants for method
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NEAR-TERM ACTIONS (continued)
- Protective Action Recommendations Guidelines
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- Additional guidelines will be developed for i
making protective action recornmendations
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beyond the 10-mile emergency planning j
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zone based on calculations and empirical
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NEAR-TERM ACTIONS (continued)
- Near-term corrective actions will be l
completed by Ap.ril 15,1997 l
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- Remedini exercise
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-To be coriducted by May 15,1997
- Demonstrate = effectiveness of corrective actions
- Demonstrate our ability to implement the f
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LONG-TERM ACTIONS Review the current Enanual and
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automated dose assessment policies, procedures, training and use of instrumentation and dose calculations software
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LONG-TERM ACTIONS
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(continued)
l Conduct a review of procedures and
calculations beyond those associated with primary-to-secondary leak rates
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- Limitations associated with calculation
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- March 5 exercise ~ identified weakness in
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already initiated, root cause analysis i
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and corrective actio'ns l
- TMI is at a high state of emergency readiness and the results of our
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corrective-actions will be used to further
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Proposed Corrective Action Plan for 3/5/97 EP Exercise -
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b corrective actions identi6ed below can be. characterized as short tenn ( accornplished in
next 2 or 3 weeks)'or intennediate tenn ( accomplished in next 1 to 2 months):
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1)' Develop guidelines for handling discrepant information. These guidelines will be developed.
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by a EP/R=p:SiiipOps groupby 3/14/97.
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2) General Emergency EAL Trairig for the foHowing poshions: ED, ED. assistant, ESD,
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ESD namWantlRAC, Group Imder R&EC, TSC Coor.,;and Tech Support Rep. Training to
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training. This tmining to be mahed by EP group by 3/24/97. '
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t 3) EP Center by center coaching drius wiH be conducted to assure that communication.
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4) The technical information Sow e$nducted in the EOF to the state will be impmved in two
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phases. Phase one will consist of a memo from the EP Manager to the ESD's and EOF Tech Support Reps describing the appropriate guidelines to be followed - memo to be sent 3/14/97.
- Phasetwowiuconsist ofi.La and dMtrithat'theseguidelinesareunderstoodviathe
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EOF center drills - to be completed by 4/15/97.
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5) The Prima:y to Secondary leakrate calculation method will beewieweMer improvement-
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Other B&W plants wiH be contacted for method c++;- 1:ri Any improvements will be
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added to the Calculation Guide used during EP activities. 'Ihe objective is.to understand limitations and give appropriate guidance for situations wiiere accurate leakrates can't be
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6) Evaluation offuir.=Mt consideration of. PAG process to anta outside the 10, mile radius, e.g. addition to the Grtmp Imader RAEC' checklist - EP to complete by 4/15/97.
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7) Engineering will c-_
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wiu strive to place the available engineering resources in the most eyyivpiiate positions.
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8) A root casse evaluation ( to include effectiveness ofpast corrective actions ) win be performedbyNSA arid EPby4/15/97.
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'9) An exercise will be performed to evaluate the effectiveness of tiie corrective actions.. It is ap-M that.the exercise will be scheduled in early May 1997.
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TT)TAL P.O?
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