IR 05000298/2001012
| ML020040093 | |
| Person / Time | |
|---|---|
| Site: | Cooper  |
| Issue date: | 01/02/2002 |
| From: | Howell A Division of Reactor Safety IV |
| To: | Denise Wilson Nebraska Public Power District (NPPD) |
| References | |
| EA-01-298 IR-01-012 | |
| Download: ML020040093 (31) | |
Text
January 2, 2002
SUBJECT:
NRC INSPECTION REPORT 50-298/0112; PRELIMINARY WHITE FINDING (COOPER NUCLEAR STATION)
Dear Mr. Wilson:
On December 3, 2001, the NRC completed an inspection of your Cooper Nuclear Station. The enclosed report documents the inspection findings, which were discussed onsite on October 18, 2001, and in a telephone conversation on December 3, 2001, with members of your staff.
The inspection examined activities conducted under your license as they relate to safety and compliance with the Commissions rules and regulations and with the conditions of your license.
The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel. The inspection consisted of a review of the licensed operator requalification program. Findings identified during the inspection are discussed in detail in the enclosed inspection report.
This report discusses a finding that appears to have low to moderate safety significance. As described in Section 1.R11 of this report, your process for examination development and validation combined with the similarity of each examination resulted in an apparent compromise of your 2000 biennial requalification written examinations. This finding was assessed using the operator requalification human performance significance determination process as a potentially safety significant finding that was preliminarily determined to be White; i.e., a finding with some increased importance to safety, which may require additional NRC inspection. The issue has a low to moderate safety significance because it represented a failure to recognize an apparent examination compromise and the resultant failure of operators on the written requalification examination, a number of whom performed licensed duties without remediation.
The finding also appears to be an apparent violation of NRC requirements and is being considered for escalated enforcement action (EA-01-298) in accordance with the General Statement of Policy and Procedure for NRC Enforcement Actions (Enforcement Policy),
Nebraska Public Power District-2-Before the NRC makes a final decision on this matter, we are providing you an opportunity to request a Regulatory Conference where you would be able to provide your perspectives on the significance of the finding, the bases for your position, and whether you agree with the apparent violation. If you choose to request a Regulatory Conference, we encourage you to submit your evaluation and any differences with the NRC evaluation at least one week prior to the conference in an effort to make the conference more efficient and effective. If a Regulatory Conference is held, it will be open for public observation. The NRC will also issue a press release to announce the conference.
Please contact Mr. Anthony Gody at (817) 860-8159 within 10 days of the date of this letter to notify the NRC of your intentions. If we have not heard from you within 10 days, we will continue with our significance determination and enforcement decision and you will be advised by separate correspondence of the results of our deliberations on this matter.
Since the NRC has not made a final determination in this matter, no Notice of Violation is being issued for this inspection finding at this time. In addition, please be advised that the number and characterization of the apparent violation described in the enclosed inspection report may change as a result of further NRC review.
In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy of this letter and enclosure will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRCs document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Arthur T. Howell III, Director Division of Reactor Safety Docket: 50-298 License: DPR-46
Enclosure:
NRC Inspection Report 50-298/01-12
REGION IV==
Docket:
50-298 License:
DPR 46 Report No.:
50-298/01-12 Licensee:
Nebraska Public Power District Facility:
Cooper Nuclear Station Location:
P.O. Box 98 Brownville, Nebraska Dates:
October 15 - December 3, 2001 Inspectors:
Paul C. Gage, Senior Operations Engineer Ryan E. Lantz, Operations Engineer Approved By:
Anthony Gody, Chief, Operations Branch Division of Reactor Safety
-2-SUMMARY OF FINDINGS IR 05000298/2001-12; on 10/15-12/03/2001; Nebraska Public Power District; Cooper Nuclear Station, licensed operator requalification report.
The inspection was conducted by two regional operations engineers. The inspection identified one Green finding, and one finding whose significance was preliminarily evaluated as White.
The significance of each issue was indicated by their color (green, white, yellow, red) and was determined by the Operator Requalification Human Performance Significance Determination Process in Inspection Manual Chapter 0609.
Cornerstone: Mitigating Systems
TBD. The licensee had compromised their 2000 Biennial Requalification Written Examinations. This constitutes an apparent violation of 10 CFR Part 55.49 for engaging in activities, which compromised the integrity of an examination.
The finding was preliminarily evaluated as having low to moderate safety significance because after identification of the compromise, the corrective action process (compensatory actions) failed to adequately evaluate the requalification examinations for the effects of the compromise. Had the licensee performed a detailed question analysis and regraded the requalification examinations by removing those questions where compromise was indicated, at least two licensed operators would have failed instead of receiving their original passing grade. Subsequently, at least two operators were returned to licensed duties without completion of the required retraining and testing for having failed the examination (Section 1R11).
- Green. During the 2000 Annual Operator Requalification Operating Test, two out of seven total crews failed the dynamic simulator portion of their operating test.
The safety significance of this finding was very low because the overall crew failure rate was less than 34 percent, the crews were not performing licensed duties, and the failed crews were appropriately retrained and retested prior to being returned to licensed duties (Section 1R11).
Report Details 1.
REACTOR SAFETY R11 Licensed Operator Requalification a.
Inspection Scope This inspection evaluated licensed operator performance in mitigating the consequences of events, since poor licensed operator performance results in increased risk through increased operator recovery rates and licensed personnel-induced common-cause error rates assumed in the licensee's individual plant examinations (IPEs). This inspection effort of the licensed operator requalification program included the following major areas: (1) facility operating history, (2) requalification written examinations and operating tests, (3) licensee training feedback system, (4) licensee remedial training program, and (5) conformance with operator license conditions.
Operator performance since the last requalification program evaluation was assessed to determine if performance deficiencies have been addressed through the requalification training program.
Examination security measures and procedures were evaluated for compliance with 10 CFR 55.49. The licensees sample plan for the written examinations was evaluated for compliance with 10 CFR 55.59 and NUREG-1021 as referenced in the facility requalification program procedures. In addition, the inspectors: (1) reviewed the number of applicants and pass/fail results of the written examinations, individual operating tests, and simulator operating tests; (2) interviewed personnel regarding the policies and practices for administering examinations; (3) observed the administration of three dynamic simulator scenarios to one requalification crew by facility evaluators, including an operations department manager assistant and plant manager, who participated in the crew and individual evaluations; and (4) observed two facility evaluators administer two job performance measures in the control room simulator in a dynamic mode.
The inspectors reviewed the licensee's process for revising and maintaining an up-to-date licensed operator continuing training program, including the use of feedback from plant events and industry experience information.
The inspectors verified the adequacy and effectiveness of the remedial training conducted since the last requalification examinations and the training planned for the current examination cycle to ensure that identified licensed operator or crew performance weaknesses during training and plant operations were addressed.
Remedial training and examinations for examination failures were reviewed for compliance with facility procedures and responsiveness to address areas failed. The inspectors also reviewed the remediation documented for three individuals, one of which involved two written examination failures and one a simulator examination failure.
-2-Maintenance of license conditions was evaluated for compliance with 10 CFR 55.53 by review of facility records, procedures, and tracking systems for licensed operator training, qualification, and watchstanding.
b.
Findings Written Examination Administration The inspectors found that the written examinations developed for the 2000 requalification cycle were adequate; however, the examinations were compromised during the validation process. This finding was preliminarily determined to have low-to-moderate safety significance (White). Final significance determination of the apparent violation is still under NRC review. An apparent violation of 10 CFR 55.49, Integrity of Examinations and Tests, was also associated with this finding.
The licensees 2000 requalification written examination was developed from the requalification training program sample plan. From this sample plan, 35 learning objectives were selected on the percentage of time that the various objectives were taught. Those same 35 learning objectives were used for each of the seven examinations that were developed and administered.
The five operating crews were given their respective examinations over the first five weeks of training cycle 00-20, one crew the first week, the next crew the next week, and so on. Inactive and other staff active licensed operators were given their examinations in the sixth and seventh weeks of the cycle. The first-week crew performed validations of the second-week crew's examination, and the second-week crew performed validations for the third-week crew's examination, and so on. The fifth-week crew also validated the examination for the staff crew of the sixth week. The crews were administered their respective examination the day after completion of validation of the next weeks examination.
The validation was conducted by the entire crew, with half of the crew taking one half of the examination to be validated, and the other half of the crew taking the other half of the examination. The entire crew then met together with members of the training staff to review comments on each question, if there were any, and gather validation times. This validation methodology did not continue after the fifth week.
To ascertain if the examination was administered in an equitable and consistent manner, the inspectors compared each question on each examination to the corresponding question validated by that crew. The inspectors noted that the examinations had numerous similarities week to week. First, the order in which the learning objectives were tested was not changed from week-to-week. The first question on the examination administered during the first week tested the same objective as the first question on each of the subsequent weeks examinations. Second, more than half of the questions on the first weeks examination for both the senior and reactor operators were very similar and tested the same knowledge as their counterpart questions on the second weeks examination. The inspectors' analysis showed that four
-3-of the five senior operator examinations and one of the five reactor operator examinations contained more than 50 percent of questions that were similar in knowledge required to answer the question as those that the respective crews validated.
The inspectors' independent analysis of the similarity between requalification examinations was conducted as follows: Each set of questions was reviewed to determine what skill or knowledge was being tested, and if that skill or knowledge was similar to that required to answer the question that was validated by a crew. The inspectors then compared crew performance week-to-week to determine if: a) any crew that had validated a similar question performed substantially better than crews that had not validated a similar question, or b) any crew that had not validated a similar question performed substantially worse than any crew that had validated a similar question. This was done for each crew and question set on the examination. There were 35 questions on each examination, 7 of which were unique to the senior operator examination, 7 unique to the reactor operator examination, and 28 questions common to both examinations. Therefore, a total of 42 question sets were reviewed.
The inspectors concluded that the validation process combined with the similarity of the examination questions resulted in a significant potential for inequitable and inconsistent examination administration. To assess the impact of this finding, the inspectors evaluated each operating crews performance on the written examination from question to question.
Of the 42 question sets, the inspectors' analysis determined that at least 8 questions demonstrated clearly that the examination was not administered in an equitable or consistent manner. Four of these questions were common to both the senior reactor operator and reactor operator examinations, 3 were unique to the senior reactor operator examination, and 1 was unique to the reactor operator examination. Crew performance on Questions 10, 15, S31, S32, and R35 supported a conclusion that the examination was not administered in an equitable and consistent manner.
For example, Question S31 on the senior reactor operator examinations administered during the first three weeks of the examination cycle were determined to be similar by the inspectors. Each question required the examinee to determine what sodium pentaborate solution concentration was required for system operability given either standby liquid control tank temperature or level. This question was answered by interpreting one of two graphs in Technical Specification 3.1.7. Question S31 on each senior reactor operator examination administered during the fourth through seventh weeks of the examination cycle was also similar to one another, but were very different from the first three weeks questions. These required the examinee to evaluate rod scram time testing data and evaluate what technical specification action may be required. Each of these last four questions required reference to Technical Specification 3.1.4. The learning objective being tested by Question Set S31 was knowledge of entry level conditions for technical specifications. All crews performed very well on this question, with the exception of Crew 3, which was the only crew that did not validate a similar question, since they validated the week four question. The inspectors concluded that the crew performance on this question supported a conclusion that the examination was not administered in an equitable and consistent
-4-manner. No evidence supporting that Crew 3 should have done more poorly on this question than the other crews for any reason other than the validation process was identified.
During the administration of the 2000 requalification examinations the licensee observed that the content and structure of the examinations coupled with the validation methodology, created a potential for pre-conditioning the crews. Problem Identification Report (PIR) 4-10812 entered this observation into the licensees corrective action process in August 2000. The inspectors found the resolution of PIR 4-10812 narrowly focused on adherence to station procedures and did not effectively investigate the potential compromise. In August 2001, a licensee internal notification again questioned the potential compromise issue. The root cause report that followed this notification again failed to address the 2000 requalification examination compromise issue, and made it a long-term corrective action to investigate the potential compromise and its effects on the 2000 requalification examination. The licensees final analysis of the compromise issue, which was entered into the corrective action process in November 2001, concluded that the results of the question analysis did not support a finding of compromise, and that no further actions were warranted. The facility analysis results are provided in Attachment 2.
The inspectors reviewed the licensees final examination question analysis that was provided to the NRC on November 15, 2001. The inspectors noted that for 18 of the 42 question sets, the licensee's analysis of examination question similarity between crews agreed with the inspectors' analysis. For 9 additional question sets, the analysis differed by only 1 question of the set, and for 4 others the analysis differed by 2 questions of the set. Therefore, the facilitys and inspectors similarity analyses were in substantial agreement for 31 of the 42 question sets.
While the licensees analysis was very similar and consistent in many cases with the inspectors' analysis, the licensees conclusion was nonconservative, in that, it did not address whether the examination was administered in an equitable and consistent manner. This nonconservative conclusion appears to have been based on an inappropriate interpretation of the data. For example, the licensees analysis stated that there were 6 questions for which an apparent compromise could not be ruled out based on the results. The analysis also concluded that for 6 questions, where an apparent advantage should have been realized, the results showed that crews who reviewed a similar question performed worse than a comparative crew that reviewed a different question. The licensee analysis stated that this inconsistency supported a conclusion that no compromise occurred on the examination. The inspectors did not agree with this conclusion because the validation method itself would produce inconsistent results, in that, the degree to which any individual in a crew gained benefit could vary significantly, and that compromise could not be ruled out for at least 6 questions. The inspectors concluded that if the examinations were regraded with the removal of questions that showed evidence of compromise, at least two individuals would have failed. These individuals were returned to shift duties without the retraining and re-evaluation that would have been required for an examination failure.
-5-10 CFR 55.49 states, Applicants, licensees, and facility licensees shall not engage in any activity that compromises the integrity of any application, test, or examination required by this part. The integrity of a test or examination is considered compromised if any activity, regardless of intent, affected, or, but for detection, would have affected, the equitable and consistent administration of the test or examination. This includes activities related to the preparation and certification of license applications and all activities related to the preparation, administration, and grading of the tests and examinations required by this part. 10 CFR 55.59 (a)(2) requires each licensee to pass a comprehensive requalification written examination which covers a 24-month requalification program.
Contrary to the above, the licensee developed and administered their 2000 Biennial Licensed Operator Requalification Examinations in a manner which compromised the integrity of the examinations for all five operating crews that took the examinations. The development of similar examinations and subsequent use of the operating crews to validate the next weeks examination prior to taking their own examination resulted in a compromise of the integrity of the requalification examinations. The two staff crew examinations were not compromised during the validation process. This was an apparent violation of 10 CFR Part 55.49 (AV 50-298/0112-01).
The inspectors determined that the examination compromise was more than minor.
Failure to administer an equitable and consistent requalification examination as part of a continuing training program had a credible impact on safety because operators were returned to shift duties without demonstrating an adequate level of knowledge. Failure of operators to properly conduct licensed duties could credibly affect the operability and availability of mitigating systems.
This operator requalification written examination security compromise was preliminarily determined to have low to moderate safety significance (White) using Appendix I to NRC Manual Chapter 0609, Operator Requalification Human Performance Significance Determination Process. The inspectors determined that the validation methodology used by the licensee combined with the similarity of the questions from examination to examination resulted in the compromise in the security of the examinations. The inspectors further determined that once the issue was discovered by the licensee in August 2000, immediate compensatory actions were not taken.
Operating Test Administration During the 2000 Annual Operator Requalification Operating test, two out of seven total crews failed their dynamic simulator test. The finding was determined to be more than minor because inadequate crew performance could adversely alter expected initiating event frequencies, or given an accident sequence, demonstrate an inability to carry out expected actions to mitigate the consequences of the accident.
Both conditions would increase the overall plant risk and have a credible impact on safety (FIN 50-298/0112-02).
-6-Using the Operator Requalification Human Performance Significance Determination Process in NRC Inspection Manual Chapter 0609, Appendix I, the inspector determined the finding concerning crew failures to be of very low safety significance (Green). This determination was based on the fact that two of seven operating crew failures in August 2000 were Green, as determined by the matrix, the prior year operating test had no findings of Green or higher, and that the failed crews were appropriately remediated before being returned to shift work.
No additional findings were identified.
4OA6 Meetings, including Exit The team discussed preliminary findings and other minor observations with Mr. Wilson, Vice President, Nuclear, and other members of the licensee's staff, on October 18, 2001. A final telephonic exit meeting was conducted on December 3, 2001, when the team discussed these findings with members of the training and operations staffs. The licensee provided no further comment on other findings or issues.
Licensee management did not identify as proprietary any materials examined during the inspection.
ATTACHMENT 1 KEY POINTS OF CONTACT Licensee M. Boyer, Senior Manager, Technical Services T. Chard, Manager, Radiation J. Christensen, Assistant Training Manager D. Cook, Manager, Training M. Coyle, Assistant Vice President P. Flemming, Manager, Licensing J. Fox, Assistant Operations Manager R. Gardner, Senior Manager, Quality Assurance M. Gillan, Manager, Work Control B. Houston, Manager, Quality Assurance Operations J. Hutton, Plant Manager D. Kimball, Assistant Manager, Radiation D. Kunsemiller, Manager, Risk and Regulatory Affairs D. Linnen, Senior manager, Training W. Macecevik, Manager, Operations D. Pease, Operations Supervisor M. Schaible, Supervisor, Operations Training D. VanderKamp, Licensing D. Werner, Lead instructor, Licensed Operator Requalification N. Wetherell, Assistant Plant Manager D. Wilson, Vice President, Nuclear NRC M. Hay Resident Inspector ITEMS OPENED AND CLOSED Opened 50-298/0112-01 AV Licensed operator requalification written examination compromise involving an apparent violation of 10 CFR 55.49 (EA-01-298)
Opened and Closed 50-298/0112-02 FIN Two of seven simulator operating test crew failures occurred during the 2000 annual requalification operating test.
-2-DOCUMENTS REVIEWED The following documents were selected and reviewed by the inspectors to accomplish the objectives and scope of the inspection and to support any findings:
Procedures Reviewed:
Operation Desk Guide (ODG) 206, Development of Non-Faulted and Faulted JPMs Operation Desk Guide (ODG) 210, Operations Department Examination Security Operation Desk Guide (ODG) 213, Annual Licensed Operator Requal Examination Develpment PIR OTHER NAIT 4-10812, 8/10/2000 Nuclear Training Procedure (NTP) 4.1, Training Material Development and Revision Nuclear Training Procedure (NTP) 4.2, Examination Development Nuclear Training Procedure (NTP) 5.2, Examination Surveillance Procedure 6.SLC.601, SLC Tank Sampling, Revision 2, Nov 26, 1998 RCR 2001-0715, Potential Examination Compromise (Near Miss) During the Licensed Operator Requalification Biannual Written Examination - 2000. Aug 6-16, 2001 NPPD: Notification: 10096568, 7/10/2001 Results Summary for 00-20 Requal Written Examinations Weeks 1-7 Licensed Operator Requalification Written Examinations, Cycle 00-20
ATTACHMENT 2 Facility Analysis Results