IR 05000341/1990003

Insp Rept 50-341/90-03 on 900212-16.No Violations, Deviations or Deficiencies Noted.Major Areas Inspected:Plant Emergency Preparedness Exercise Including Observations by NRC Representatives.Exercise Weaknesses Assessed

ML20012D834
Person / Time
Site:	Fermi
Issue date:	03/16/1990
From:	Patterson J, Snell W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20012D832	List: IR 05000341/1990003 ML20012D831
References
50-341-90-03, 50-341-90-3, NUDOCS 9003280438
Download: ML20012D834 (24)

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W U.S. NUCLEAR REGULATORY COMMISSION

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REGION.III

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Report.No.. 50-341/90003(DRSS)

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Docket No. 50-341

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.V Licensee:.The Detroit' Edison Company

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L 6400 North Dixie Highway

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Enrico Fermi Nuclear Power Plant; Unit:2 Facility Name:

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. Inspection At:. Fermi:2 Site, Newport, Michigan

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Inspection Conducted:

February 12-16, 1990

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J[G//o Inspectors: LJ at

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Team Leader

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Accompanying' Personnel:

D.'Barss,

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J. Jamison, F

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G. Martin'

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R. Van Neil.g

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! Approved By: ' Wi 1,

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A Radiological Controls and

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Emergency Preparedness Section

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Inspection Summary

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Inspection on Februarv 12-16, 1990 (Report No. 50-341/90003(DRSS)).

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, Areas Inspected:

Routine, announced inspection of the Fermi 2 Nuclear Power'

Plant's; emergency preparedness. exercise including observations by'five NRC

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representatives of key functions'and'1ocations during the exercise.(IP 82301).

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~Results:. No; violations, deficiencies, or deviations were identified.

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. licensee demonstrated a good response to a fast moving scenario that resulted.

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in a'large offsite release of radioactivity as well as to a' fire.in the Standby

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' Gas; Treatment Syst'em, Division II train.

Two Exercise Weaknesses were-

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-assessed.

One was for not recognizing the Emergency Action Level conditions

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' and classifying a. Notification of Unusual Event (NUE) - Objective No. 4.,

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The other was for an inadequate Medical Drill - Objective No. 22.

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i DETAILS

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Persons Contacted

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NRC Observers and Areas Observed

J. Patterson, Technical Support Center (TSC) and Emergency Operations Facility (EOF)

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'J. Jamison, Control Room / Simulator and TSC

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U G. Martin, Operational Support Center (OSC) and Medical Drill D. Barss, Offsite Monitoring Teams and Medical Drill F

R. Van Neil, EOF

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Detroit Edison Company S. Catola, Vice President, Nuclear Engineering and Services W. Orser, Vice Presidenti Nuclear Operations

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A. Settles, Superintendent, Technical Engineering G. Preston, Director,. Nuclear Training

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a R. Eberhardt, Superintendent, Radiation Protection R. McKeon, Superintendent, Operations L. Goodman, Director, Nuclear Licensing G. Trahey, Director, Special Projects

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R. Kelm, Sr. Director, Nuclear Safety T. Riley, Supervisor, Compliance D. Wells, Radiation Protection S. Neal, Security Specialist T. Dong, Engineer J. Mulvelull, Supervisor, Radiological Emergency Response

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Preparedness (RERP)

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K. Morris, Emergency Response Planner, RERP

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W. Lemerand, Clerk RERP

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Specialist, RERP J. Sweeney, Emergency Response,Special~ist, RERP P. Piggott, Emergency Response j

P Fesd er. Director, Plant Safety'

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All names listed above attended the exit interview on February 15, 1990.

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2i Licensee Action on Previously Identified'Open Items (IP 92701)-

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.(Closed) Exercise Weakness: Open' Item No. 50-341289019-01:

The licensee failed to demonstrate a successful completion of the

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assembly / accountability function within the established timeigoals during

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the 1989 emergency eu rcise.

Installation of additional card readers at the TSC, the OSC, and the Alternate OSC plus improving the plant Public q

Address.(Hi-Comm) for communicating with several outlying buildings have

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resulted in a more efficient and thorough system.

These revisions plus practice-drills and a successful accounting of'400 individuals in 25 minutes with none missing during the 1990 exercise have closed this item.-

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General s

'L An exercise of.the licensee's Radiological Emergency Response Preparedness (RERP) plan was conducted at the Enrico Fermi Atomic Power Plant Unit 2 on February 14, 1990.

This exercise tested the licensee's I

4-capabilities to respond to a hypothetical accident scenario resulting j

in a ir.cjer release of-radioactivity..This was a full participation

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chercise 10 that the emergency facilities of the State of Michigan, Wayne County and Monroe County were fully operational.- An NRC Region-III

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Site Team participated as players interfacing with the licensee's emergency response exercise participants.

Also participating were the NRC Region III j

Incident Response Center (IRC) and the NRC Headquarters Emergency j

Operations Center,

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This exercise scenario; as demonstrated, included a full-scale plume j

exposure for the 10 mile emergency planning zone (EPZ) and a partial scale' ingestion pathway response.

A medical drill was conducted independent from the exercise'on February 15, 1990, which demonstrated the onsite radiological medical response capability at the Fermi 2 site.

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Attachments to this report include a description of the exercise scope

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and objectives and the sequence'of events.

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General Observations

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Procedures

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The exercise was conducted in accordance^with 10 CFR Part 50,

l-Appendix E requirements using the Fermi RERP Plan;and the Emergency e

Plan Implementing Procedures (EPIPs).

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Coordination

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The licensee's response was coordinated, orderly, and timely.

If the events had been real, the actions taken by the licensee would

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have been sufficient to permit the State and local authorities to take appropriate actions to protect the health and safety of the public.

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Observers s

Licensee observers monitored and critiqued this. exercise along with five NRC observers.

Representatives of the Federal Emergency Management Agency (FEMA) observed and evaluated the adequacy of offsite agencies.- Their findings will be presented in a separate report issued by FEMA.

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The licensee held facility critiques following the exercise.

The K1C evaluation team discussed the strengths and weaknesses identified during the exercise at the exit interview held on February 15, 1990.

Personnel who attended the NRC exit interview are listed in Section 1.

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g A public meeting was conducted at the Monroe County Courthouse, P

Monroe, Michigan, on February 16, 1990, in which NRC and FEMA representatives presented to the public preliminary findings based on the onsite and offsite evaluations.

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Specific Observations a.

Control Room (CR)/ Simulator t

t The CR crew's response to scenario / simulator conditions was conducted c.

quickly and correctly using the alarm response procedures and

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Abnormal Operating Procedures (A0Ps)..The Nuclear Shift Supervisor

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l(NSS) and the Assistant NSS (ANSS) were decisive and clear in their

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e assessment of the plant and direction of the operator responses.

At L

0736, the Off Gas Radiation Monitor Alarm alarmed and at 0737 the L

Nuclear Supervising Operator (NS0) followed his Alarm Response Procedure and referred to the ADP.

Also, at that time the Turbine h

Building Area Radiation Annunciator, Channel 35 was activated.

The, steam jet air ejector (SJAE) room recorder indicated 103 mr/ hour.

At 0739,-the System Supervisor was notified.

He gave orders to the

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NSO to " start backing power down." At 0742, the_0ff Gas Radiation

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Monitors increased.

The ANSS was-directed 'to' decrease. power to 60%

at a " faster rate." These events were followed by others including r

p the activation of a plant area alarm and an announcement made that.

K high area radiation was present.

At 0748, the Main Steam Line High'

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Radiation Monitor Alarm sounded; and the reactor tripped on high ' _

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radiation in the-steam line.

This. led to the Alert being. declared at 0750, based on severe fuel clad failure (Tab 9, Page 4 of the

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s Emergency Action Levels (EALs).

The NSS did not recognize that an EAL for the declaration of'c

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flotification of Unusual Event (NUE) was satisfied when the Off

't has High-High Alarm was confirmed.

This EAL is identified in

' Implementing Procedure EP-101, Enclosure A, Tab 9, Page 3 of 35.

Also, there was no entry in the NSS's log to identify the EAL conditions which would identify them with an emergency classification.

This failure to classify the NUE is an Exercise Weakness.

Open Item No. 50-341/90003-01.

Since the NUE was never declared, the'NRC team, as participants, were not informed at NRC Headquarters of the related event conditions.

In addition, when information concerning the Alert declaration at 0750 was communicated to the NRC, the information on the conditions that met the NUE 4_

declaration earlier were not transferred to the NRC.

-The NSS did not announce to the CR crew when he assumed the role of initial Emergency Director (ED); nor did he announce.to the CR staff when he' relinquished that position to the TSC Emergency Director.

The CR Communicator was unaware of this transfer of command and

.cD control until 16 minutes later when he asked the ED in the TSC if he was officially the ED yet.

This transfer was announced on the site wide PA system to all other emergency response facilities (ERFs).

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the NSS and the ED from the TSC prior to the transfer of command and i

control.

At that time, the NSS stated to the ED that he was aware

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i, of the NUE conditions addressed earlier, but that he did not declare

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'the event because'of rapidly escalating plant conditions leading to-

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the Alert'.

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Not'ifications to the State and Counties for the Alert were completed

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within 15 minutes as required.

The NRC was officially notified in r

less than one hour after the declaration.

L The CR crew performed well considering the fast moving scenario.

I The CR crew could have been more vocal in accomplishing their tasks and in verbalizing their thought processes as well as carrying out

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their discussions openly and in clear _ voices.

The Controllers

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should recognize that'the NRC evaluator may need to be alerted

to important discussions or actions taking place out of earshot.

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i Based on the'above findings, with the exception of the Exercise Weakness, this portion of the licensee's program was acceptable.

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Technical Support Center (TSC)

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Immediately following the Alert declaration at'0750 assembly and L

accountability was initiated.

This was completed in 25 minutes for a total:of 400 people with no. personnel missing.

This activity was well performed and demonstrated good coordination between the Security officers and the onsite personnel.

The newly installed

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card readers in the TSC, OSC, and Alternate OSC were a real asset in i;

performing this task accurately and efficiently.

While the TSC was'

still in the activation process'(0803).and before the ED declared the TSC_ functional at 0830, the' Radiation Protection Advisor gave a

good initial briefing about current plant' conditions to the arriving TSC staff.

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The ED gave frequent and worthwhile briefings =to;the staf_f.

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However, it appeared that these' briefings could have done. more to '

focus and direct the efforts'of the TSC staff towards,the priority problems.

The ED could ha've directed the support group leaders to vocalize on the status of'their areas of responsibility,.rather than

'just having him making the presentation.- The one time that the ED was observed asking for status briefings by his support group.

leaders, he neglected to have them use the microphone.

This would have allowed all TSC personnel to be apprised of specific emergency

related information and improved the general flow of information-

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within the entire TSC.

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At 0936,-the emergency escalated to a General Emergency (GE) based on the site boundary dose rate.

The posted projection,was 4.68 Rem (child thyroid) at the site boundary based on'an eight hour release duration.

No announcement was made to the TSC and other' emergency

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L response facilities that a release was in progress.

The initial r

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i Protective Action' RecommendatiN (PAR) was to: shelter _ all sectors.

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e in a two mile radius and five' miles downwind in Sectors'R,1A, and B.

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Discussions between the ED and the Emergency Officer (E0) in the EOF

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concerning the GE classification and resulting' PAR indicated a'need-

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a-for clarification of the EAL' statements and possibly a need for

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additional training in their use.

Making. PARS based'on integrated

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dose.(or dose commitment) while classifying 4the event based on dose

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' rate can be confusing,~ particularly, where calculated values for -

J both are presented side by side on the rintout, one in Rem and the

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other in millirems /per hour..

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v LThe ED directed his. staff to' assess the effect on offsite dose

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upon starting the Reactor Building Vent Exhaust fans to provide

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L an unfiltered release path,to improve on the plant habitability.

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This occurred at approximately 1043 when the Standby Gas Treatment System (SGTS) was secured.

No result of that assessment was

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identified at the termination of the exercise.

Simulated potassium iodine was not provided to the reactor building l

entry team after they left an' extremely high airborne radiation area, although the need and potential benefit was recognized.

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TSC maintained a continuous phone connection with the State of Michiganandtransmittedradiationdataandinformationtothe State s, representative.

The. heating, ventilation, and air conditioning system (HVAC) was not initiated by the ED because of

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the high noise level already evident in the TSC.

He. stated in his assessment that this would be done in a real emergency.

Otherwise, the TSC habitability was monitored with a continuous air monitor and

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sn ion chamber survey meter at the Radiological Advisor's station.

The TSC staff was reminded to read their self-reading dosimeters

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approximately every half hour.

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Status boards were well maintained throughout the exercise.

The TSC Technical: Communicator did a good job of receiving and transmitting E

vital reactor related information and other data, and from his vantage point observed entries on the status boards,. correcting-

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them when necessary.

He served as a good conduit for the ED,' as

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well.

.The initial fire alarm announcement (0951) was later followed at-1004 by a report of a fire in the SGTS Division II train.

As discussed.in Section 5.c, the Fire Brigade Leader did not realize

that Division I SGTS was not operating.

There was good communication between the ED and the OSC Coordinator on how to fight the fire in

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the SGTS charcoal filter trays. 'After some' discussion, the ED directed the OSC Coordinator.to start the Reactor Building Heating-

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Ventilation and Air Conditioning (RB HVAC).

Also, the ED told him to

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stop the SGTS and dump the C0.

Meanwhile, depressurization of the

reactor continued to 65 psig.

These requests were carried out; but the SGTS kept running and the fire was not extinguished'at 1024.

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D The NRC Site team began arriving at approximately 1035.

They were given a briefing soon after arrival.

By 1130, the SGTS fire was out.

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By noon, the Engineering Support Team still couldn't determine where i

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all the radioactivity was coming from. They couldn't believe that

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,f all of it resulted from the Reactor Water Cleanup Unit leak,

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In summary, the TSC performed well.

The support groups ware i

diligent and utilized the SPDS for most reactor parameter data

and also the Automatic Dose Assessment Program where applicable.

Communications within, as well as to other ERFs, were well maintained.

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h Based upon the above findings, this portion of the licensee's J

program was acceptable.

However, the following item should be

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considered for improvement:

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Effort should be made to clarify the EAL statements relating.

to dose rate and the related PARS which are based on integrated

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dose.

Both these values as calculated appear as adjoining data values on computer printout sheets.

Either one could be i

improperly,used as indicated.

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Operational Support Center

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The OSC was staffed _and activated in a timely manner at 0809.

The first team went through their preparation to obtain an Accident Range _ Noble Gas Monitor-(AXM) sample in the Auxiliary Building.

Dosimetry was acquired and Self-Contained Breathing Apparatus (SCBA) checked out, but SCBA itse was simulated.

If the SCBA was worn instead of being simulated, communications between the inplant teams and the OSC would have"been severely hampered.' A means to practice

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communication under these conditions or an alternate means of i

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communication should be developed.

The Radiological Protection

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Technician (RPT) did not have anything with him to record dose rates or other pertinent information. As the team entered the Auxiliary Building,,there was a high noise environment for radio reception.

Ear pieces would have helped.

The HPT took a floor smear at 0905, but he did not record information on thefsmear.

By 0912, the RPT had taken approximately six smears with no,information being recorded on

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them, and nothing but his hand in which to carry them.

He also had

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no form or paper of any kind on which to record general area dose

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rates.

An HPT only simulated having turn-out gear when accompanying the

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Fire Brigade (FB) enroute to the SGTS where the fire was located in the charcoal filter train.

The primary dispatch location for firemen's gear, including turn out gear for the HPT, was not used.

The secondary dispatch location near the Radiation Control area entrance did not have fire protection gear for the HPT.

He should have been fully outfitted since he is an assigned member of the FB.

At 1017, on instructions from the FB Leader, the CO2 was manually activated. However, the SGTS train was still running; therefore most of the CO2 was drawn out with little effect on the fire.

The FB

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Leader is an Operator, and he did not receive an initial briefing message which stated that Division I SGTS was out of service.

While using radio transmission back to the OSC, the HPT neglected several i[

times to include the statement, "This is a Drill." At 1030, it was observed that the CO2 system could be refilled from outside the area.

No one appeared to consider this option.

The FB members L

did a good job of considering and issuing stay times for the team.

A Post Accident Sampling System (PASS) sample was requested at

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1117. The PASS team team went through all required preparations and briefings before reaching the sampling site.

These PASS sample efforts were aborted at 12S2 because of necessary system realignment.

j Since OSC communications rely heavily on radio transmission, if the

teams had been actually wearing SCBAs, as conditions warranted,

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communications would have been significantly impaired.

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I There appears to be many areas within the plant where the plant paging system cannot be heard.

For instance, within the OSC, outside the CR door, and in the vicinity of the AXM sample station, f

On several occasions personnel were observed using two-way radios

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in close proximity to panels containing caution signs warning that two-way radios should not be used within six feet.

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To summarize the OSC's performance, it can be stated that problem solving was good.

Data inanagen.ent and record keeping was poor.

Some additional examples of inadequate information management are as follows:

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r Information received from the field by the Radiological

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Emergency Team Leader and his assistant was written on note pads, " post-its" and other informal strips,of paper.

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Information on dose received by individual team members was

recorded on the OSC status-board.

However, it.was not clear

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who was comparing and adding these to the individual's dose l'

histories.

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The team briefing / debriefing form was not completely filled

out.

Signatures were not filled in and debriefing information added upon completion of team assignments.

The only person using a log sheet was the OSC communicator.

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The end destination of most information received by thi OSC was

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the status board.

The status board is not an adequate record for purposes of documentation and reconstruction.

Better information management would aid problem solving, team tracking, and team briefing efforts.

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These examples of. inadequate'0SC documentation and apparent lack of:

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m an adequate information management system will be tracked as Open

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50 341/90003-02.

Item No.

Based upon the.above findings, with the exception of the open item, this portion of the licensee's program was acceptable; however the

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following item should be considered for improvement:

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Less simulation for repair teams.and HDTs assigned to the rire

Brigade as relating to use' of respirators and SCBAs especially

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if airborne radioactivity is present or could be a possibility.

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Emergency Operations Facility (EOF)

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Within two to three minutes after the Alert was declared, the

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Nuclear Operations Advisor (NOA) and the Emergency Officer (EO)

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arrived..The N0A activated the SPDS display terminal, and the EO was updated on the plant status.

The Alert, which was declared at

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-0750 in'the'CR, was not announced in the EOF until 0805.

At 0816,

the E0 was notified that all EOF personnel present at that time were accounted for.

The Radiological Protection Technician (RPT) checked

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the air monitor and radiation survey meters.

At 0838, the EO

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announced that all participants should have dosimetry.

The EOF ventilation system was switched to recirculating mode, and the E0 confirmed that the system had HEPA filters.

Initial contact from EOF to_the State of Michigan was at 0850.

The Assistant E0 was briefed on meteorology conditions and anticipated wind shifts.

At 0915,.there was-a briefing prior to a turnover of offsite responsibilities from the ED in the TSC.- This included PARS and communications with government agencies.

This briefing was received

on the E0's speaker phone, so all'in the vicinity could hear this key l

information.

At 0925, after these well executed activities were conducted, the E0 declared the EOF functional.

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The ED in the TSC and the E0 in the E0F initially disagreed on whether,the EAL conditions were reached to declare a General-Emergency (GE).

The TSC ED stated that conditions-existed-for the GE based on 5 Rem / hour dose rate for a child's thyroid 1 The E0F dose assessors were not getting these values.at that time (0935).

A further discussion ensued between the TSC and the E0F including discussion of integrated dose vs. dose rate..The EAL values were in dose rates.

Both.the TSC and EOF agreed to child thyroid levels

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of >5 Rem / hour.- This resulted in' the GE being officially announced

on the PA at 0941.

Notifications were made to the State including-

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initial: PARS within four minutes of the GE declaration.

Continuous communications were maintained with the State since the EOF was declared functional, as they were in the TSC.

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'There was a good use of status boards in the EOF, for example meteorology, trending of Division II AXM, and containment rad ation monitoring.

The PARS were well~ discussed with the State.

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were transmitted, State actions were confirmed and options were s

E considered.. Very good interactions were demonstrated., A security check point was established.at the, entrance to the EOF, 'Also a

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radiation safety step-off pad was" established to limit ~or exclude contamination possibilities. '

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The NRC team arrived at 1026 and were' briefed by the E0 in a:

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separate conference room less than ten minutes later.'

The licensee's-

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staff'and those NRC participants assigned to the. EOF seemed to work well together, as demonstrated by several good exchanges'of views and suggestions for mitigating the~ accident.

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TheNOA:performedwellasreactor/tecbnical'spEcihlistfor<inplant equipment.

Someone in the EOF learned' earlier of a reported message

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that a radiation release was identified as coming from the Turbine-Building-HVAC.

The N0A could not identify the source of.this

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information for approximately two hours.

It was finally: determined from a Public Affairs person that the On-Call Plant Supervisor transferred.this erroneous information to'a licensee media

' representative prior to the Joint Public-Information' Center being actively involved in the exercise.

Fortunately,'this' erroneous information was not released to the public, even though it was

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misconstrued piece of information from'the exercise scenario.

The offsite teams were well dispatched with good communications demonstrated by the Radiological. Emergency Team (RET) Coordinator.

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The large Emergency Planning Zone map was an excellent tool for the

~ RET Coordinator and dispatcher.

It had easily discernible markings t

for streets, intersections of streets, township. designations, natural landmarks, etc.;

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Overall, the~ EOF performed well and maintained good communications.

and interactions with the State and the TSC.

Briefings by the E0 were frequent and objective in nature.

Interactions with the NRC

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Site Team were constructive.

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W When conditions in the SGTS were restored, the release ended.

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.The exercise was terminated at 1314 with a message from the

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CR/ Simulator.

Recovery-activities were planned for the following day.

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Based on the above findings, this portion of the licensee's program-

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was acceptable.

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Offsite Monitoring Teams

k The RET Supervisor reported promptly to the RET Dispatched Area-in the Monroe, Customer Services Office after being notified by pager b

at.0758.

The Radiation Protection Technicians (RPTs) assigned to

'the RET. arrived almost immediately after the RET Supervisor.

This

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seemed rather early. since the Alert was just : declared at 0750..The<

,

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team members would not have had time,to. travel from.the site to the'

l

' Monroe' Customer' Service Office'in such a short time.

Apparently-

,

these individuals were assigned to fill. RET positions in; anticipation

-

of, exercise events. -Three Customer Service Representatives werei g

assigned as drivers for the RETs.

Within 45 minutes of arrival, all three teams had completed their

.

'

preparation, including checking out their monitoring equipment,.

and were ready for assignment.

Initial' dispatching and briefing

were welk conducted.

Plume search and tracking were started.

One team was assigned near the site, another was dispatched.further out.

>

The unavailability of a Controller delayed the dispatching of the'

third team.

Frequent updates were provided;on the plant emergency.

classification level, weather conditions, and the' progress of the

,

,.

offsite release and anticipated radiological conditions.

Both RET--

teams observed demonstrated proper techniques in identifying the

,

,

plume boundaries and center line.. Winter weight gloves should have.

,

been provided to protect the RETs' hands from the wind chill effects

'

of' holding a sur.vey meter outside a moving vehicle window.

These.

'

,

gloves were unavailable, but definitely needed.

Appropriate survey

'

'

forms were completed accurately in a timely manner by the RET members.

"

One survey meter that.was used did not have a Beta correction factor

. posted on the meter.- The combination'of Customer' Service Representatives as. drivers and RETs made a very. effective team._

.

These' drivers were very knowledgeable of the roads and directions to

.

,

follow.

They could follow most of the dispatcher's instructions for monitoring routes without the aid-of maps.. The set of maps =available to'the team contained both traditional' maps'as well as, highlighted 4

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aerial photographs which greatly aided accurate and rapid..

J

l identification of. survey points.

These maps and aeriali hotographs-p were excellent and definitely; state of-the-art for' field monitoring :

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teams.

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W The collection of,a-soil sample;was: observed..The RET' inappropriately selected a four inch plug of grass covered soil.

This was.not in accordance with Procedure EP-220, Personnel Monitoring and" Radiological Emergency Teams,- Step 2.3, Enclosure 1A,? Tab'8.

,

This' procedure states-that the; soil sample-should be.taken from an approximate three. feet square area and not moreithan 1/2 inch deep, without vegetation in the sample.

Countirate information-was not

'

available from the Controlleh for. environmental samples.

This should

-

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have been provided.. Theonejair'sampleitakenwasnot' observed.

With three teams available, it was expected that more than one soil sample and one air sample would be taken.

With'known particulate and iodines released, as indicated by the reported onsite samples, more offsite samples should have been-taken.

Due to the few environmental samples taken, and the inappropriate techniques used s

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in ob' aining the soil sample, environmental sampling ability' needs

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improving.

Discussion with RET personnel indicated that'" hands-on" l

training in environmental sampling has.not been provided, only

)

classroom training, ImprovementsonthemethodologyforprepaNng,

'

p'.

' labeling, and handling of field samples, e.g., water, soilf and H

I vegetation are recommended.

To_ accomplish this, more training in

.This' area' is.needed with " hands-on" sampling practices being'a vital part:of.this traini_ng.

This environmental' sampling responsibility has been. identified as an Open Item No. 50-341/90003-03..,

'

'

L Radio communications between the RET Coordinator and the HPTc were

._

adequately demonstrated.

When necessary, repeat back messages were given and clarifications'provided to ensure accuracy of the.

1 information exchanged.

The use.of personal vehicles owned by

..

,

non respirator qualified personnel assigned to offsite monitoring

!~

teams would severely limit offsite monitoring capabilities in situations where a particulate release wnuld require the'use of respiratory protection equipment (Reference Step 5.3.4 of -

-

,

Procedure EP-220,. Personnel Monitoring and Radiological Emergency

' Teams).

The lack of protective clothing and respiratory protective

!

o equipment'for RET use without reporting to the plant could also

'

'

,

delay'or' hinder offsite monitoring capabilities.' There were no protective clothing or respiratory protective equipment included I

in the RET offsite kit or in the onsite kit.

These two types of

'

1.

items'should be included in the RET kits for both 'onsite and offsite.

,

Personnel exposure was mon _itored continuously for each team member

as well;as the time spent within the plume.

However,' exposure j

history was not evaluated for: RET members.

It should have been t

'

considered when personnel were assigned to the teams.

.I Based on the-~above findings, with the exception of the open item

>

_ialready identified,.this portion 'of the licensee's program was acceptable.

However, the following items should be considered

i for improvement.

.;

.

Ensure that the' Beta Correction Factors are provided as i

appropriate for the survey. meters befpre their. usage.

j Provide protective ~ clothing and respiratory protective

equipment in both the onsite and offsite RET kits.

!

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Consider previous personnel exposure history before assigning

>

personnel to the RET's.

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A f.

Medical Drill y

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V" The mechanics of' preparation for the drill were considered to be

'

1acking in several details which adversely affected the players lin:

,

demonstrating their true proficiency.

The scenario did not contain adequate' data for contamination levels on responders who entered the posted areatand handled the victim.

The area that the drill was~

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staged'inwas:notposted" Airborne'RadioactivityArea"asrbquired

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J by the scenario.

Trash rectptseles were not prop kly lined in

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9, accordance with Ma'ndard licensee Oractices.

Additionally,

Cont; rollers were nnt always availa)le atistrategic locations to

,

.onsure that appropriate drilloinformation was communicated.

In

,

,

particular, the initial message to the CR did not indicate that the

r

.

.3 reported event was.a drill.. The Control LRoom Controller took action ~

,

and had the iMtial medicalfdrill announcement repeated correctly.

.On several occasions personnelfwere mo'nitoredtfor contamination

level withc% a Controller providing the data needed to represent

"

the cro p w t&IAnat'en which would haVe: occurred.

These essential

.

. detailWWuld 'cw provided by Controllers to present a more realistic

.

and bali W abin situation to m sp eding personnel.

Medical; personnel arrived in a tinely inanner 'and appropriately

evaluated the medical and radiolo0ical concerns.

F.rst aid measures were implemented to treat the victim's primary and s1 secondary injuries with appropriate consideration for the existing

.

-radiologicel conditions at the-accident scene.

The HPTs responding

','

n;'<

to thn drill adequately assessed the radiological and medical i

'

conditions,at the scene.. The radiological information that was

-

,

obtained was conveyed to the. medical personnel.

No documentation of the radiological survey was completed by anyone at the scene.

One HPT was observed taking floor smears without recording the locetion

,

information, Actions were taken to cortrol and prevent the spread of contamination

,

from the accident scene as the victim was transported to a, lower

,

background area for monitoring..The survey performed on the victim k

,

as he.was removed from the radiologically controlled area and:

transferret' to the waiting ambulance team could have been_more

' complete.

This was partially due to inadequate scenario data and lack of more aggressive Controller action.

'

(

An Emergency Medical Technician was interviewed and reported that he had no problem with obtaining quick access to the protected area.

A Security Guard met the incoming ambulance at the Security Gate and accompanied the vehicle and personnel while onsite.

,1

' As the victim was transferred to waiting-ambulance personnel, appropriate information concerning the medical and radiological g.

conditions were provided verbally to the ambulance team.

However,-

-.

as listed in Procedure EP-225, Radiological Medical Emergencies, Attachment 1,.a body map was.not provided.

This was required in

-

'

accordance with Step 6.3.2 of the same procedure.

Two other procedural steps of EP-225 were not followed.

According to i

'

Step 5.8.3.2, the Thermoluminescent Dosimeter (TLD) and.self-reading WJ dosimeter (SRD) should have been removed from the victim as he was

!-

taken nut of the Radiological Controlled Area and replaced with dosimetry.from the ambulance emergency kit.

The victim's TLD was l'

removed, but.it was never replaced with another TLD from the s

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ambulance' emergency kit. - The EMTs responding from offsite used the

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'of fsite' ambulance kit which is in the ambulance.

This kit contained

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'n l-only:SRDsand'alcharger.

TLDs were not providsf for the responding

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EHis.. Step;6.3.1.2 of Procedure EP-225 directs =the radiation

'

w-protection personnel to provide the ambulance crew.with dosimetry.

og

'T Failure to provide proper dosimetry for recording a perma ~nent record-

. of-exposure to either the victim or ambulance personnel during

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transportation to an offsite medical' facility is a serious omission, y

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i This and other inadequacies or omissions; relating to the overall

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W-

-conduct of this medical drill, which have been enumerated in this

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section of this report,-resulted in an Exercise Weakness which will

,(

be tracked as Open Item No. 50-341/90003-04.

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With the exception of the~ Exercise Weakness, this portion of the

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licensee's~ program was adequate.

However, the following. items

'

u should be considered for improvement.

'

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The scenario should be given more: care in preparation to

include sufficient radiological 6atasfor contamination levels

-

onthe.responderswhoenteredthepostedareaanddirecyly

' '.

handled the victim.

..

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Controllers should have been more aggressive and actively

~

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involved as must as their role permits; o

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6.

-LJcenseeInterfacewithNRCEmergencyResponders

+

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.TheNRCwas'initiallynotifiedofthe.Alertdeclaraiionandsu'bsequent-

,

reclassification through the Headquarte'rs Operations;0fficer Within the

regulatory time. limit.

However, as. indicated earlier.in thistreport,' the

'

'

'NRC was not adeq'uately informed of the postulated ^ plant conditions which'

resulted in the abnormal radioactivity levels in the reactor coolant.

+

Lack of sufficient information on the probable cause!of the abnormal

"

activity. level created _some uncertainty forfseverhl hours among reactor.

safety teams in-the Region III Incident Response Center'(IRC) and J

.4 i

Headquarters Operations Center (HQOC) regarding the root cause.of the -

'

high primary containment radiation levels since core uncovery had not taken place.

f

' Licensee communicatorsimaintained open line communications-over the Emergency' Notification System (ENS) and Health Physics Network (HPN)

'

lines as requested by NRC staff, in accordance with regulatory

'

y requirements.

Early in the response, NRC communicators requested

"

. periodic updates of reactor, containment, and'inplant radiological t

',

. parameters that were relevant to the accident scenario,tas well as

.

updates'of onsite meteorological data.

Licensee communicators

'

occasionally had to be reminded by NRC responders to transmit these

,,

data, which were being closely monitored and trended by IRC and HQOC staffs.

As the' exercise progressed, there were several. breakdowns in transmitting,these types of data and field survey data to remotely-located NRC staffs.

However, the apparent root causes of these problems

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_ _ _, _ _ _ _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. _, _ _ _, _ _ _ _ _ _ _ _ _ _ _ _

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were either poorly phrased req'ues'ts or misunderstandings-by NRC staff e regarding which types of data were more readily'available,from the TSC versus'the EOF.

ThereLwerenotindicationsmof3anyiintenttowithhold information, although several NRC: staff later' indicated that the licensee

'

seemed slow to respond to several-technical questions t'ransmitted to

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licensee communicators.

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An NRC Site Team oflabout 25 persons reached the site at about 10:30 a.m.' Most of.the Site Team reported to the= EOF, while others

'

deployed to the TSC, OSC, and the Joint Public'Information Center.

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An NRC representative also was sent directly to the State Emergency

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Operations Center.

Counterpart seating arrangements, telecommunications provisions, and workspace for Site Team personnel were good.

The Si.te.

,

Team' Leader and his staff were given a timely and detailed chronological

,

briefing by;the E0.

Subsequent briefings were also well detailed.

There'

,

were'no'significant interface problems between the Site Team and licensee

,

counterparts. ' Licensee staff promptly responded to the Site Team's information needs and kept their NRC counterparts adequately informed of changing onsite and offsite-information.

'7.

Scenario The scenario was' radiologically challenging and accomplished the-goalsof: driving the onsite exercise; however as described in Section 5 f, Medical Drill, that scenario did not include sufficient radiologic'al data for-contamination levels on the responder.

c Events relating to the Reactor Water Cleaning System and to the Standby Gas Treatment System were based on real time events las indicated by the licensee's scenario development group, t

'

Large inconsistencies between the level of core damage, mode of failure, reactor building activity, and effluent values were noted and questioned by the. licensee and the NRC participants,, alike.

With a little mon.

effort, the' scenario could have reflected a much<more realistic and.

consistent picture of the hypothetical plant events.

.

8.

Exit Interview

'

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The. inspection team. met on February 15, 1990 with the licensee.

"

representatives denoted in Section 1-of this report.

The team leader discussed the scope and evaluation of the exercise. -Because of the rapid escalation of events, especially those which resulted in an upgraded

-

emergency classification, the creditability of the events was at times difficult to' comprehend.

The participants gave forth a good coordinated s'

effort; however, our OSC observations identified the need for better documentation for routine radiation survey information, radiation dose

records for inplant team members, and: briefing / debriefing' forms.

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k Theassembly/accountabilitydrill,wasverywellconddctedandtherelated

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Exercise-Weakness from the 1989 exercise will be closed. -The Emergency; g'-

q Preparedness Supervisor was contacted on February 22,1990; to inform her.

-

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that~ upon review off our: preliminary findings which'were statad on-

!

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February 15, 1990 at the Exit Interview, Region III had decided'that two et of the areas had been identified.as Exercise Weaknesses.

These were the-

-inability to_ demonstrate recognition,of EAL conditions which would'have

resulted in an'NVE (Refer'ence Section 5.a); and exp'osure control during

'.

the Medical Drillt was unsatisfactory.: (Reference-Section 5.f).

q

,

The Team' Leader extended thanks to the licensee for their graciousness and cooperation in working with the Region III Site' Team which participcted-

.in the exercise as well as the NRC Executive Team in Bethesda, Maryland'

'and the Region III Base Team which responded from Glen Ellyn, Illinois, t

.

'According to the licensee, none of the-information discussed-during this-9'

meeting was proprietary.

'

Attachments:

'

1.

Exercise Scope and Objectives

"

2.

Sequence of Events and Scenario Time Line

.

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FERMEX-90 Scenari) Package

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Py 1.0 EXERCISE SCOPE FERMEX-90 will demonstrate the ability of the Fermi 2 Emergency Response Organization to respond to a simulated offsite radiological release end to communicate and coordinate with offsite governmental agencies. This is a full participation exercise in that the emergency facilities of the State of Michigan, Wayne County, and Monroe County will be fully operational. The exercise requires a full-scale plume exposure, partial-scale ingestion pathway response.

.

Conducted independently of the FERMEX-90 scenario will be the onsite radiological medical emergency drill at the Fermi 2 site and the offsite radiological medical emergency drill in Wayne County.

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FERMEX-90

I

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. Scenario Package j

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2.0. EXERCISE OSJECTNES During FERMEX-90 the Fermi 2 Emergency Response Organization will demonstrate the ability to:

1.

Implement the Radiological Emergency Response Preparedness Plan using existing procedures.

'

'l 2.

Respond to and mitigate the effects of a simulated radiological emergency to protect the health and safety of the public.

. 3.

Classify events in accordance with the Emergency Action Levels.

4.

Activate the Emergency Response Organization commensurate with the emergency i

classification.

!

5.'

Notify State and local governmental agencies within 15 minutes of emergency classification and provide periodic follow-up reports.

.,

6.

Notify the Nuclear Regulatory Commission with 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> of emergency classification.

,

.( -

7.

Account for all personnel in the Protected Area within 30 minutes of ordering assembly.

8.

Perform security access control to the site.

l

' g.

Perform radiological surveys and implement exposure controls to protect the health and

' safety of plant personnel.

10.

Authorize exceeding 10CFR20 exposure limits as required by the scenarlo.

- 11.

Perform habitability surveys and maintain access control of the Operational Support I

Center, Technical Support Center and Emergency Operations Facility.

12.

Demonstrate issue and use of personnel doslmetry in the Technical Support Center and the Emergency Operations Facility.

13.

Establish and maintain communications between the Emergency Response Facilities (Simulator Control Room, Operational Support Center, Technical Support Center, Emergency Operations Facility and Joint Public Information Center).

" 14.

Transfer respon'sibility for offsite notifications, emergency classifications and protective action recommendations from the Simulator Control Room to :he Technical Support Center.

'

15.

Transfer responsibility for offsite notifications and protective action recommendations from the Technical Support Center to the Emergency Operations Facility.

'

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16.

Perform potential and actual offsite dose assessment calculations based on plant i

parameters and meteorological conditions.

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FERMEX-90

Scen:ria Packaga j

l 17.

Recommend to' State officials Protective Action Guidelines for the general public in the l

10 mile EPZ based on offsite dose assessment calculatione, plant conditions and meteorological forecasts within 15 minutes after a General Emergucy declaration.

j

.18.

. Utilize Offsite Radiological Emergency Teams to locate and track the plume by

measuring field radiation levels and airborne radioactivity levels.

I g.

Utilize Offsite Radiological Emergency Teams to collect environmental samples as

,

required by the scenario, transport samples to the Emergency Operations Facility laboratory and perform sample analysis, q

20.

Provide updates to the JPIC Media of authorized information through press releases and media briefings whenever significant changes occur, e.g. emergency classification,

'

meteorological conditions, radiological release or protective action recommendations.

21, Activate the Utility Mutual Assistance Pact.

-

During the onsite emergency medical drill, which will be conducted independently of the FERMEX-g0 scenario, the participants will:

L

'

. 22.'

Respond to the radiological medical emergency in accordance with established procedures.

. (-

23.

Contact offsite response agencies in accordance with established procedures.

,

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Perform radiological surveys, monitor personnel exposure and control contamination at L

the eccident scene, ambulance transfer site and hospital treatment room.

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' FERMEX-90 Scenario Package

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Page 1 SEQUENCE OF EVENTS

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TIME '

KEY EVENTS 0700 Initial Conditions: Reactor operating at 90% power, increasing load to maximum output. SGTS DIV I out of service for corrective maintenance. Power increase

'

begins immediately after turnover.

0710 Slow increase in off-gas release rate.

.

j'

0725

. Annunciator 3D8 "DIV I/II OFF-GAS RADN MONITOR UPSCALE"

l 0730 Annunciator 3D12, *DIV I/ll OFF-GAS RADN MONITOR HIGH-HIGH".

AOP 20.000.07, " Fuel Clad Failure" entered and reactor power decreased in accordance with AOP.

t-Reactor coolant and off-gas chemistry analyses requested by Control Room.

,...

0735 Unusual Event declared based on Loss of Fuel Clad Fission Product Barrier (EP-101,

[;

l Tab 9, page 3)

Notifications to Offsite Authorities ordered.

0750 MSIV closure due to high main steam line radiation. Reactor Scram. ALERT declared based on " Severe Fuel Clad Failure" (EP-101, Tab 9, page 4)

- Assembly and Accountability ordered.-

Notifications to Offsite Authorities ordered.

L.

l-

0850 Small RWCU failure in Secondary Containment occurs resulting in release of coolant.

Annunciator 1D70 " STEAM LEAK DETECTION DIFF TEMP HIGH" received and RWCU inboard and outboard isolation valves close.

RB ventilation trips and isolstes, SBGT DIV ll auto starts 0855 Site Area Emergency declared based on either loss of two fission product barriers (Fuel Clad and Reactor Coolant, EP-101, Tab 9, page 18) or dose rates > 1 rem /hr in

'

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the plant (EP-101, Tab 11, page 4)

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.* FERMEX-90

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-l s. Sienar13 Package Page 2

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_ (h%

M8 SEQUENCE OF EVENTS TIME KEY EVENTS 2 alls to discharge due to open thermister.

0950 Fire in SOTS DIV ll train. ' CO f

Radiolodine and particulates release begins.

Annunciator 16D27 " Fire Alarm" received and fire in zone 16 Indicated on fire detection mimic.

,

AOP 20.000.22, " Plant Fire * entered.

AOP 20.000.18, " Control of the Plant from the Dedicated Shutdown Panel * entered Fire Brigade dispatched to assess and fight fire.

0950 -

General Emergency declared based on offsite doses > 1 rem /hr at the Site boundary 1030 (EP-101, Tab 1, page 8).

-

Protective Actions Recommendations to the state issued by Emergency Officer.

!

1000 --

ERO fights fire, attempts to restore SGTS and continues to monitor

~ (J 1300 offsite radiological conditions.

1300 SGTS restored. Radiolodine and particulates release ends,

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END PLUME EXPOSURE BEGINNING OF INGESTION PATHWAY ACTIVITIES FOR OFFSITE FACILITIES

-

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aimdLATED 24 HOUR TIME JUMr--------------

SCENARIO TIME NOW 02/15/90

1.

1315-

- Exercise terminates for onsite participants. JPIC and State EOC remain activated for L

Ingestion pathway response.

!

1330 Ingestion pathway activities at JPIC and State EOC.

L-1530 Exercise terminates offsite.

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.FERMEX-90 -

. Scenario Package

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Q Page 1 SEQUENCE OF EVENTS TyE, KEY EVENTS 0700 initial Conditions: Reactor operating at 90% power, increasing load to maximum output. SGTS DIV i out of service for corrective maintenance. Power increase begins immediately after turnover.

0710 Slow increaso in off-gas release rate.

0725 Annunciator 308 "DiV I/11 OFF-GAS RADN MONITOR UPSCALE *

0730 Annunciator 3D12, *DIV I/II OFF-GAS RADN MONITOR HIGH-HIGH".

AOP 20.000.07, " Fuel Clad Failure" ontered and reactor power decreased in accordance with AOP.

Reactor coolant and off-gas chemistry analyses requested by Control Room.

0735 Unusual Event declared based on Loss of Fuel Clad Fission Product Barrier (EP-101,- Tab 9, page 3)

Notifications to Offsite Authorities initiated 0750 MSIV closure due to high main steam line radiation. Reactor Scram. ALERT-declared based on " Severe Fuel Clad Failure" (EP-101, Tab 9, page 4)

Assembly and Accountability ordered.

Notifications to Offsite Authorities initiateri RB ventilation trips and Isolates, SBGT DIV 11 auto starts 0850 Small RWCU failure in Secondary Containment occurs resulting in release of coolant.

Annunciator 1070 " STEAM LEAK DETECTION DlFF TEMP HIGH" received and RWCU inboard and outboard Isolation valves close.

0855 Site Area Emergency declared based on either loss of two fission product barriers (Fuel Clad and Reactor Coolant, EP-101, Tab 9, page 18) or dose rates > 1 rem /hr T

in the plant (EP-101, Tab 11, page 4)

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a FERMEX-90

Scenario Package

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Page 2.

-g SEQUENCE OF EVENTS TIME KEY EVENTS 0950 Fire in SGTS DIV 11 train. CO2 falls to discharge due to open thermister.

Radiolodine and particulate release begins.

Annunciator 16D27 " Fire Alarm" received and fire in zone 16 Indicated on fire detection mimic.

,

AOP 20.000.22, " Plant Fire" entered.

AOP 20.000.18, " Control of the Plant from the Dedicated Shutdown Panel" entered P

Fire Brigade dispatched to assess and fight fire.

1000-EF.O fights fire, attempts to restore SGTS and continues to monitor 1300 offsite radiological conditions.

1030-General Emergency declared based on offsite doses > 1 rem /hr

'

1050 at the c!:o boundary (EP-101, Tab 1, page B).

Protective Actions Recommendations to the State issued by Emergency Officer.

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1300 SGTS restored. Radiolodine and particulate release ends.

Exercise terminates for onsite participants. JPIC and State EOC rcmain activated-for ingestion pathway response.

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END PLUME EXPOSURE BEGINNING OF INGESTION PATHWAY ACTIVITIES FOR OFFSITE FACILITIES l

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SIMULATED 24 HOUR TIME JUMP SCENARIO TIME NOW 02/15/90

x 1330 Ingestion pathway activities at JPIC and State EOC.

1530 Exercise terminates offsite.

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END OF PLUME EXPOSURE BEGINNING OF INGESTION PATHWAY ACTIVITIES FOR OFFSITE FACluTIES

• • SIMULATED 24 HOUR TIME JUMP *

SCENARIO TIME NOW 02/15/90 1430

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