IR 05000346/1987015

Insp Rept 50-346/87-15 on 870529.Inspectors Concluded That Shift Supervisor Was Dozing or Sleeping at Desk on 870524. Event Isolated & Caused by Excessive Use of Overtime & Supervisor Use of Medicine to Control Asthma

ML20216F976
Person / Time
Site:	Davis Besse
Issue date:	06/19/1987
From:	Guldemond W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20216F933	List: IR 05000346/1987015 ML20216F928
References
50-346-87-15, NUDOCS 8706300988
Download: ML20216F976 (6)

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.U.S. NUCLEAR REGULATORY COMMISSIO REGION III

' Report Nol 50-346/87015(DRP)

Docket No; 50-346 License'No. NPF-3-

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Licensee: Toledo' Edison. Company Edison' Plaza 300 Madison Avenue Toledo, OH 43652-Facility Name: Davis-Besse Nuclear Power Station, Unit 1 LInspection'At: Davis-Besse-Site, Oak Harbor, Ohio Inspection Conducted: May 29, 1987 Inspectors: Leonard G. McGregor Robert eFay t Approved By: W u .mo d, Chie [

-Reactor ojects Branch 2 Date Inspection Summary-Inspection on May 29, 1987 (Report No. 50-346/87015(DRP))

Areas Inspected: This was a special inspection to determine the circumstances surrounding a. reported incident of a shift supervisor sleeping on dut Results: The inspectors concluded that the shift supervisor had been dozing or sleeping at his desk for a short period of time on May 24, 1987; that this was an isolated event; and that it was not deliberate. They also concluded-that a major cause of.the incident was the excessive use of overtime resulting from the failure of the licensee to assign sufficient numbers of senior

'li_ censed operators as shift supervisors, and that medication taken by the shift-supervisor to control.an asthma condition may have contributed to the proble l 8706300900 870619 DR ADOCK0500g6

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DETAILS.

, Persons Contacted Toledo Edison Company i l

> . *D. Shelton, Vice President, Nuclear i

• G. Grime, Director, Industrial Security

• L. Storz, Plant Manager

• J. Waddell, Security Investigator, Industrial Security

• G. Honma, Compliance Supervisor i

• T. Meyer, Licensing Director l

• R. Flood, Assistant Plant Manager Operations

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• P. Byron, Senior Resident Inspector

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• D. Kosloff, Resident Inspector The inspectors also interviewed persons who were directly involved l in the incident and several other licensee personnel with no direct involvemen * Denotes those personnel attending the exit meetin . Discussion I Background

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On Sunday, May 24, 1987, the Senior Resident Inspector was informed

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by licensee personnel that a shift supervisor on duty the previous night had been observed by security personnel to be sleeping. The j Senior Resident Inspector notified Region III management of-the '

alleged incident the same day. The reactor was in cold shutdown at the time for maintenance activities with restart not scheduled for about two weeks. On Thursday, May 28, 1987, Region III sent two inspectors to Davis-Besse to conduct an independent investigatio On Friday, May 29, 1987, the inspectors interviewed 11 individuals directly involved with the incident. This included four security personnel, an assistant shift supervisor, an administrative assistant, an assistant shift technical advisor, three equipment operators, and the shift supervisor. Only one other person was directly involved, but he was not on duty that day and therefore was.not interviewe In two cases, the interviewees chose to have a union steward present during the interview (all interviewees were offered that option).

All interviews involving the principal parties were conducted jointly by the two inspectors. From these interviews, the inspectors obtained j the following information about the incident, j

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b. Incident The shift supervisor alleged to have been sleeping was assigned _ to a 12' hour rotating shift. On May 24, he was on his second backshift (from 8:00 p.m. May 23 to 8:00 a.m. May 24) of that rotation. Early in the shift he had mentioned to the assistant shift supervisor that he'had had trouble sleeping the previous day and only had about three or four hours of sleep during the previous 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />, and was very tired. Around 1:00 a.m. on May 24, it was noted by the assistant shift supervisor that the shift supervisor's head was occasionally " bouncing" so he talked to him on several occasions to assure himself that the shift supervisor was awake. Other plant personnel had also entered the shift supervisor's office on official business during this general time frame and noticed his head nodding down with his chin on his chest. Some of these people asked the shift supervisor questions and in one instance a locked valve log was given to him for initialin In every case, the shift supervisor responded to the questions or requests for initial At about 2:38 a.m. on May 24, a security officer observed the shift-supervisor sitting at his' desk with his head tilted down and his 1 chin on his chest apparently sleeping. He notified his supervisor 1 of the situatio Prior to the supervisor's arrival, two other security officers also observed the nodding position of the shift supervisor. At about 3:10 a.m., the security supervisor entered the shift supervisor's office are By that time the shift supervisor appeared to be awake and aler An administrative assistant who has an office adjacent to the shift supervisor's office with a window between the two offices also noted the shift supervisor sitting in his chair with his head down and his chin on his chest. The shift supervisor himself acknowledged to the inspectors that he had been extremely tired that night and probably dozed in his chair as alleged, although he could not remember any detail Prior to the incident, he said he had performed routine duties in the plant and at about 1:00 a.m. had returned to his office to perform routine administrative chores. At the time of the incident, he had been reading the " required reading" fil :

All parties interviewed agreed that the shift supervisor was awake i and alert for the remainder of the shif c. Conclusion

The inspectors conclude that the shift supervisor was inattentive to I duty (sleeping or dozing) for a period of at least one half hour, on -q the morning of May 24, 1987, but that it was not a deliberate act, but l rather was the result of fatigu The plant was staffed adequately throughout the incident because the licensee is required to have at least one senior reactor operator licensed person on shift while the reactor is shutdown and this condition was satisfied by the assistant

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shift supervisor, who is a senior licensed person and also was on shif Furthermore, because the reactor was shutdown there were minimal safety implication . Causes of the Event The licensee at the time of the event had only four senior licensed operators assigned as shift supervisors and they were working 12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> shifts routinely (from 3:00 to 8:00). This schedule had been implemented for several weeks and was contrary to NRC policy on overtime and was a violation of Davis-Besse procedures on the use of overtime. (For more discussion of this issue, see Inspection Report No. 50-346/87008.) A major cause of the incident appears to be excessive use of overtime resulting from.the licensee's failure to assign adequate numbers of senior licensed personnel as shift supervisors. Medication taken by i'

the shift supervisor for an asthma condition may have contributed to the problem. When informed of this conclusion during the exit meeting, the licensee informed the inspectors that as of that day it had corrected this problem temporarily by assigning staff personnel who hold senior reactor operator licenses to work as shift supervisors until such time that permanent shift supervisors can be licensed. With these new assignments, the shift supervisors will work eight hour shift . Other Discussion Extent of the Incident The inspectors were concerned whether this incident was indicative of a routine problem or whether it was an isolated event. Their conclusion is that it was isolated. This is based on tlie responsu received from all of the interviewed personnel when they were asked if they had ever seen or had been aware of any personnel (licensed or unlicensed) sleeping on duty. Several of the interviewees recalled an instance within the last year where a contractor employee working as a fire watch (a compensetory measure when 4 fire doors or fire detectors are inoperable) was found sleeping and immediately was escorted from the site and his employment terminated. The NRC was aware of that incident. Other than that incident, no one could recall seeing or having any specific knowledge of any licensed person sleeping on duty. This response was provided not only by the 11 people directly involved with this incident but by other licensee personnel who were interviewed. Furthermore, this also was verified by an NRC contractor person who spent greater than 50%

of his time at Davis-Besse for almost a year in 1986 observing the System Review and Test Program test These tests were conducted at all hours of the day or night and therefore this person spent many hours on the back shift The NRC also is aware of one other incident in early 1985 where an unlicensed operator (an equipment operator) was assigned to monitor for pipe leakage in the auxiliary feedpump room while the startup feedpump was being operated and was found sleeping by an NRC inspector. This person was given a one day suspension by the licensee and the NRC imposed a violation and civil penalty in the amount of $100,000 for the inciden .

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b. Failure to Wa'ke Shift Supervisor During the' course of this inspection, the-inspectors were puzzled that--although several licensee personnel apparently observed the shift supervisor to be dozing or sleeping,- some of'them made little or no effort to wake him. When asked why, several.of the interviewees-stated that they were' reluctant to do so.because of his status as the highest member of. plant management onsite during the back shifts. The inspectors pursued this issue.with several of the interviewees to determine if there is' friction between various work groups. In general, the responses were that there is no friction-and that working relationships are cordial and helpful. A.few of the respondents, however, stated that friction does exis Some of.the non-licensed personnel were of the opinion that the licensed Control Room staff considers themselves to be of a higher status, and that this occasionally causes friction between the licensed and non-licensed staff. The inspectors could not verify that this situation actually exists but they do recognize that a perception of a problem can be as bad as a problem itself. The licensee therefore should investigate this and take specific action to recti fy i c. Status of Shift Supervisor The shift supervisor involved has been removed from shift pending completion of the licensee's investigation of this even Furthermore, he will be given a complete medical examination because he has a chronic asthma condition and routinely ingests several medications to control it. .These medications will be evaluated by licensee-authorized medical personnel to determine if they can cause drowsiness or any other side effect d. Corrective Actions Prior to the inspectors leaving the site, the licensee informed the inspecto" of the~ oreliminary results of its internal investigation of- this unt whic.; essentially independently confirmed the facts as stated above. The licensee also informed the inspectors of some immediate corrective actions and documented these in a letter to the NRC Regional Administrator on May 29, 1987. These actions were:

(1) Initiate a 5-section, 8-hour shift rotation instead of the 12-hour shift schedule (see Paragraph 3 above).

(2) Initiate a random backshift tour by licensee management personne (3) Initiate shift meetings to re-review the information surrounding this even I

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(4) Shift supervisors have been directed to perform backshift administrative duties in the assistant shif t supervisor's office or in the Control Roo (5) Pending the final results of the investigation, the shift ,

supervisor in question has been removed from all shift duties i regarding plant operations (see paragraph 4.c above).

The licensee committed to provide a final report _ of its investigation to the NRC when it is complete . Exit Meeting i The inspectors met the licensee representatives denoted in Paragraph 1 at the conclusion of the inspection tn May 29, 1987. The inspectors discussed the purpose and scope of the inspection and the finding The inspectors subsequently discussed by telephone the likely information content of the inspectior report with regard to documents or processes reviewed by the inspector during the inspection. The licensee did not identify any document / processes as proprietar >

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