IR 05000397/1993002
| ML17290A235 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 03/25/1993 |
| From: | Louis Carson, Mcqueen A, Pate R, Qualls P, Russell J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17290A234 | List: |
| References | |
| 50-397-93-02, 50-397-93-2, NUDOCS 9304210176 | |
| Download: ML17290A235 (36) | |
Text
U, S.
NUCLEAR REGULATORY COMMISSION REGION V
Report No.
License No.
Licensee:
50-397/93-02 NPF-21 Washington Public Power Supply System P.O.
Box 968 3000 George Washington Way Richland, Washington 99352 Facility Name:
Washington Nuclear Project, Unit 2 (WNP-2)
Inspection at:
WNP-2 Site, Benton County, Washington Inspection Conducted:
February 22 - March 2, 1993 Inspectors'.
.
Hc ueen, mergen repare ness na yst VW 3 5 1'3 ate
~gne lv
ate cygne
16 ~3 ate Soigne Approved by:
~Summar:
L.
. Carson, Ra >ation Spec> a est nspector A. S. Hohseni, Emergency Preparedness Specialist, R.
C. Barr, Senior Resident Inspector,.
WNP-2, RV gr
~ r yl Ro er
.
ate, C ie
,
Sa eguar s g mergency Preparedness, and Non-Power Reactor Branch ate S>gne NRR/PEPB
~/~'/~'
'g Areas Ins ected:
Announced inspection to examine the following portions of the licensee's emergency preparedness program:
follow-up on Open Items identified during previous emergency preparedness inspections and observe the 1993 annual emergency preparedness exercise and associated critiques; and Inspector Identified Items.
During this inspection, Inspection Procedures 82301, 92701 and 93702 were used.
Results:
In the areas inspected, the licensee's emergency preparedness program was found to be in compliance with NRC requirements within the areas examined.
Two items were identified as exercise weaknesses and several areas were indicated to the licensee for improvement.
The exercise weaknesses are described in section 8.
9304210176 930325 PDR ADOCK 05000397
il l
),
II
INSPECTION DETAILS 1.
Ke Persons Contacted
- P. Bagan, Emergency Preparedness (EP) Technical Advisor
- J. Baker, Plant Manager
- D. Larsen, Manager, Emergency Preparedness
". H. Honopoli, Manager, Support Services
- R. Noyes, Manager, Engineering Programs
- A. Oxsen, Managing Director Acting
- J. Parrish, Assistant Managing Director of Operations
- D. Pisarcik, Manager, Radiation Protection
- G. Ray, Principal Emergency Planner
- J. Teachman, Technical Data Center Core Engineer
- R. Utter, Supervisor, Emergency Preparedness Training The.above individuals denoted with an asterisk were present during the exit 'meeting.
The inspectors also contacted other members of the licensee's emergency preparedness, administrative, and technical staff and management during the course of the inspection.
NRC Personnel at Exit Interview R.
C.
L. C.
A. D.
A. S..
R. J.
P.
M.
J. J.
Barr Senior Resident Inspector, WNP-2, RV Carson, Radiation Specialist Inspector, RV McQueen, Emergency Preparedness Analyst, RV Mohseni, Emergency Preparedness Specialist, NRR/PEPB Pate, Chief, Safeguards, Emergency Preparedness, and Non-Power Reactor Branch, RV Quails, Non-Power Reactor Inspector, RV Russell, Reactor Licensing Examiner, RV 2.
Follov/ u on Previous Ins ection Findin s
MC 92701 (Open)
Follow-up Item (92-17-01).
TSC Relocation Issues A review of Emergency Plan Implementing Procedure (EPIP)
13. 10.3, Technical Support Center Operations and Technical Support Center Director Duties, Revision 9, dated May 4, 1992, contained an added
"Action 10" on page 3 of 8, which indicated that
"When advised the TSC is uninhabitable, the Plant Emergency Director will select staff members to go to the Control Room or the Emergency Operations Facility based on functional need."
The licensee confirmed that there was no alternate TSC "per se,"
and that the support expertise required in such cases would be redistributed to the most appropri'ate location to continue support.
"Open C.A.R.
Report" (Corrective Action Request)
90-0062 indicated a finding that the "Control Room (CR)
may not be adequate for handling TSC staff.
Three previous drills had scenarios that rendered the TSC uninhabitable and made it necessary to relocate TSC staff members to the CR.
Observations of this work arrangement noted that the Simulator (thus the CR)
may lack adequate space and equipment to
support this influx of personnel."
The C.A.R. remarks section indicated that
"Installation of phones in the control room is waiting for action on HWR AR 5693 (est.
completion August 92)."
This item was reviewed during a previous routine inspection and it was determined that to mount the additional telephones in the control room required a seismic evaluation, which the licensee indicated had been initiated.
During a review of this item after this emergency exercise, the licensee indicated that five specific actions should still be accomplished to complete action on this item.
This item will remain open to review progress in resolving this issue.
b; (Open)
Followup Item (92-29-01)
Review Annual Audit Corrective Actions The 1992 Annual Audit of the Emergency Preparedness Program for WNP-2 (Audit 92-596),
dated August 28, 1992, was reviewed during the last routine inspection.
The audit report Executive Summary indicated twelve deficiencies; three Safety Level II guality Finding Reports (gFRs), five Level III QFRs, one Commercial (FR, and three Observations were identified.
Two areas of significant concern were identified during the audit that require management attention:
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The evacuation process, and the response and training-of organizations and personnel in the WNP-2 Exclusion Area was found inadequate.
Several organizations would not have been notified in an emergency, and would not have heard the evacuation sirens.
Also several facilities have no emergency plans, procedures or emergency postings, and many personnel have not received emergency training.
This element of this inspection followup item (IFI) was indicated as still open by Corporate guality Assurance (gA) as of February 26, 1993.
The licensee indicated that all corrective actions pertaining to this (FR are completed except one, which has been approved and is to be implemented by April 30, 1993.
This element of the IFI will remain open until closed by gA.
~
Responsibilities and a comprehensive configuration management policy has not been adequately defined or implemented for the control of Emergency Response facilities, systems, and equipment.
Hodifications have not always received engineering approval, had
CFR 50.59 reviews performed, or been processed in accordance with Plant procedures.
Facility drawings are out-of-date and not adequately maintained or controlled, and changes were noted that cannot be identified on drawings or by personnel.
A Problem Evaluation Request (PER 292-0917)
was issued.
gA indicated that this item was= closed on December 1,
1992; therefore this element of the IFI is considered close e
The items were reviewed during this inspection and it was determined that action on one element of the IFI was completed and is closed.
The other element remains open until closed by QA.
c.
(Open)
Followup Item (92-29-02)
EOF Habitabilit uestions
~IN-92-32 One observation indicated in the 1992 annual audit report was identified by the inspector as an item to be reviewed by the NRC in future routine inspections until the issues are resolved.
NRC Information Notice 92-32, PROBLEMS IDENTIFIED WITH EMERGENCY VENTILATION SYSTEMS FOR NEAR-SITE (WITHIN 10 MILES)
EMERGENCY OPERATIONS FACILITIES AND TECHNICAL SUPPORT CENTERS, dated April 29, 1992, was addressed to all holders of operating licenses or construction permits for nuclear power reactors.
The notice
'pplies to the WNP-2 emergency operations facility (EOF)
and the technical support center (TSC).
The licensee 1992 audit indicated that
"an investigation, required by PPM 1. 10.4, is currently being performed by the Nuclear Safety Engineering Group to determine Supply System posture with respect to the Notice."
The investigation is being conducted under OER Number 85040H (Opefating Experience Review).
The OER Issue Form indicated There also may be some unanswered engineering questions regarding the lack of charcoal beds in the system, system operation in a non-pressurized mode, and the systems ability to maintain habitability as designed.
Documentation pertaining to this item was reviewed for status of
'resolution during this inspection at the site and it was indicated that only three corrective action items remain and all are scheduled for completion by March 21, 1993.
d.
(Open)
Followup Item (92-29-03)
Chan e Emer enc Plan to Re uire 12 Month Audits During the last routine inspection, an anomaly was noted in the emergency plan requirement for scheduling yearly emergency preparedness audits.
The plan indicated aq audit would be conducted
"annually" in accordance with the Plant Technical Specifications.
The plan defined "annually" as "yearly, normally between two consecutive annual emergency exercises."
CFR 50.54(t) states that "the licensee shall provide for a review of its emergency preparedness program at least every 12 months..."
Licensee Technical Specification Section (TS) 6.5.2.8 indicates that
"These audits shall encompass:
... f.
The Emergency Plan and implementing procedures at least once per 12 months per
CFR 50.54(t)."
The licensee indicated the emergency plan would be changed during its next annual revision to specifically reflect the TS requirement.
This item will be closed upon receipt of the plan change or other documentation indicating execution of the change.
(Closed)
Followup Item (92-29-04)
Dela ed Incident Re ortin During the last routine inspection, four unusual events (UE) which had been reported to the NRC Headquarters Operations Officer (HOO)
since the previous routine emergency preparedness inspection at WNP-2 were reviewed.
In each of the events, a review of the circumstances and documentation pertaining thereto indicated that the event classifications appeared appropriate and that timely notifications and follow-up notifications were made to the county and state agencies.
It was indicated that the NRC was notified of each event from 26 to 52 minutes after county and state agencies.
This appeared not consistent with regulatory requirements
'ontained in
CFR 50.72(a)(3),
which requires that
"The licensee shall notify the NRC immediately after notification of the appropriate State or local agencies and not later than one hour after time the licensee declares one of the Emergency classes."
A review of the licensee Emergency Preparedness Implementing Procedure (EPIP) 13.4. I (Notifications), indicated that offsite agenc'ies were to be notified within 15 minutes of event classification.
The EPIP further directs the NRC Communicator to provide the NRC with event information within one hour of event classification.
At the exit meeting the licensee indicated that Plant Procedures Manual (PPM) 13.4. 1 would be changed to specifically reflect the requirement in 10 CFR 50.72(a)(3).
Additionally, the plant
'manager notified Shift Managers by interoffice memorandum on September 4,
1992, to immediately implement the requirement as stated in 10 CFR 50.72 pending amendment of PPM 13.4. 1.
A review of this item during this inspection indicated that the licensee has issued a Procedure Deviation Form (Control Number 92-1068),
dated September 4, I992, which corrected Procedure 13.4. I to reflect NRC regulatory guidance.
(Closed)
Followup Item (92-AM-Ol)
S ill of Sodium H
ochlorite One unusual event (UE) had been reported to the NRC Headquarters Operations Officer (HOO) since the last routine emergency preparedness inspection at WNP-2.
On October 13, 1992, the licensee informed the NRC Headquarters Operations Officer (H00) via the NRC Emergency Notification System (ENS) that a
UE had been declared at the WNP-2 at 6.03 p.m.
due to increased plant awareness and to focus the need for additional personnel to work on an event in progress.
Approximately 100 gallons of 8 percent sodium hypochlorite (household bleach)
was
'1 i
pumped into a 6000 gallon tank containing
"Calgon PCL-8125" due to human error in hooking up the wrong connection.
A violent exothermic chemical reaction occurred, the tank hatch blew open, and a white vapor escaped.
The licensee evacuated the immediate area of the tank and cleared the area down wind on owner controlled property.
After response actions were completed and the situation was determined to be under control, the licensee terminated the UE at about 2. 10 p.m.
on October 14, 1992.
In reviewing this event during this inspection, it appeared that the event had been conservatively classified at an appropriate Emergency Action Level and that timely notifications had been made to cognizant offsite agencies and the NRC.
(Closed)
Followup Item - Exercise Weakness (92-34-01)
Failure to Declare General Emer enc During the 1992 annual emergency exercise on December 8,
1992, an area of concern was noted in that the Control Room (CR) crew failed to properly classify an emergency event.
At approximately 8:25 a.m.,
RPV level dropped to below -285 inches, which was below the Bottom of the Active Fuel.
This level remained below the Fuel Zone'ndicating range (-285 inches) for approximately 10 minutes.
During the same time period the Reactor Coolant Pressure boundary was lost due to the LOCA and Primary Containment was lost due to valve failures in the Standby Gas Treatment System (SGTS).
A release of radioactive material was in progress and indicated by radiation levels in the plant vent stack and SGTS flow rates.
Plant Procedure Hanual (PPH)
13. 1. 1,
"Emergency Classification,"
attachment 4.3 stated "Classification shall be made using conservative principles."
PPH 13. 1. 1 also stated a General
'mergency should have been declared if there was a loss of two fission product barriers and "a high potential for loss of the third."
The operator was directed t'o attachment 4.4 of the same procedure, which referred the operator to PPH 9.3.22,
"Core Damage Evaluation," for clarification of potential damage to the fuel.
The fuel was the fission product barrier with a high potential for loss.
PPH 9.3.22, section 5. 1, directed the operator to evaluate the possibility of core damage based on reactor water level history.
The inspector concluded, using these procedures, that core damage was possible during this scenario.
Core uncovery for a
10 minute period 30 minutes after shutdown would have probably caused the fuel clad to exceed 1500 degrees (F) resulting in some degree of clad failure.
1500 degrees (F) was the threshold for
'fuel rod perforation.
The inspector concluded that the use of PPH 9.3.22 should have caused the crew to decide there was a high potential for loss.of the fission clad barrier and, per PPH 13. 1. 1, declare a General Emergency.
Emergency classification was the responsibility of the Emergency Director, which was the Shift Hanager, until he was relieved of this duty at about 9: 10 a.m.
This provided the crew with 45 minutes to declare the General
Emergency from the time of the core uncovery.
Immediate corrective action taken by the licensee was to remediate the crew which failed to make the appropriate classification.
PPH 13. 1. 1 was revised to attempt to eliminate classification problems.
Additional emergency training was added to Operator requalification training in event classification.
During this exercise, Simulator emergency classification and declaration was in accordance with procedure and the crew made a timely and appropriate recommendation to the Emergency Director for classification of the General Emergency in this exercise.
h.
(Closed)
Followup Item (92-34-02)
TSC Habitabilit TSC habitability was not properly monitored or maintained during the 1992 Annual Emergency Exercise, for example:
~
The 'door to the TSC, required to be shut for TSC atmosphere isolation, remained open throughout the exercise.
The TSC Iodine and Noble Gas monitors remained inoperable throughout the exercise.
This was determined to be a
procedural problem and the procedure was revised soon after the exercise.
Wo portable atmosphere samples were taken in the TSC during the exercise.
~
No Step Off pad was established to monitor persons entering the TSC to prevent the spread of contamination.
,f This item was reviewed by observing radiation protection measures at the TSC during this exercise.
The above indicated shortcomings did not recur in this exercise and appropriate radiation protective measures appeared to have been appropriatdly implemented,
=
Exercise Plannin res onsibilit scenario ob 'ectives develo ment control of scenario The Hanager, Emergency Planning (EP)
has the overall responsibility for'eveloping, conducting and evaluating the annual emergency preparedness exercise.
The EP staff developed the scenario with the assistance of licensee staff from other organizations possessing appropriate expertise (e.g.,
reactor operations, health physics, maintenance, etc.).
In an effort to maintain strict security over the scenario, individuals who had been involved in the exercise scenario development were not to participate in the exercise.
NRC Region'V was provided an opportunity to comment on the proposed scenario and objectives.
The complete exercise document included objectives and guidelines, exercise scenario and necessary messages and data (plant parameters and radiological information).
There appeared to have been some problems in the scenario
1,I I
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as originally written and submitted.
NRC review of the original scenario submittal surfaced numerous questions and apparent shortcomings in the scenario data; all of which were discussed with the licensee in detail in telephone conversations on January 4 and February 4, 1993.
The licensee agreed that the comments and questions would be reviewed and the scenario would be changed as appropriate.
When run on the Control Room Simulator a few weeks before the exercise, the scenario required revision and was resubmitted about two weeks preceding the exercise.
Scenario problems observed during the exercise are discussed at sections S.e, 9.c, 9.e, and 10.b. I below.
The exercise document was tightly controlled before the exercise.
Advance copies of the exercise document were provided to the NRC evaluators and other persons having a
specific need.
This exercise was conducted to meet the requirements of IV.F 3 of Appendix E to
CFR Part 50.
E,"ercise Scenario The exercise objectives and scenario were evaluated by the NRC and considered generally appropriate as a method to demonstrate the Was'hington Public Power Supply System (WPPSS) capabilities to respond to an -emergency in accordance with their Emergency Plan and implementing procedures.
The exercise scenario started at about 3:30 a.m. with the reactor at 100% power.
A minimum Seismic Earthquake (.I g) occurred at 3:40 a.m.
Causing an overcurrent trip due to buss damage.
Conditions for an ALER1 occurred at about 3:45 a.m.
due to failure of the Reactor Coolant Pressure Boundary to isolate when the design logic was met.
At about 6:30 a.m.,
a.075g seismic after. shock occurred resulting in a spurious trip of the Hain Generator output breakers.
This caused a
Turbine/Generator trip and a resulting reactor SCRAM.
The reactor shut down but several control rods were not completely inserted.
This is technically an ATWS (Anticipated Transient without SCRAM) and was to drive the operating crew into the ATWS Emergency Operating Procedures
{EOP).'he High Pressure Core Spray (HPCS) diesel tripped rendering the HPCS pump inoperable.
At 7:00 a.m., level in the reactor slowly dropped until two Area Radiation Monitors
{ARH) exceeded their "Maximum Safe Operating Values" at 'which time the reactor was
"Emergency Depressurized" by opening seven Safety Relief Valves
{SRV).
The rapid loss of steam through the SRVs caused the reactor water level to decrease quickly.
At 7:05 a.m.,
as level in the reactor dropped and could not be maintained above the -192 inches level, the remaining
"Inside The Shroud/Low guality Systems" were lined up for injection into the reactor.
This met criteria for a General Emergency declaration due to "Loss of Two Barriers And Potential Loss of Third."
pump A did not open due to the disk being jammed into the seat and Low Pressure Core Spray (LPCS)
was not able to function.
The level in the reactor continued to drop, uncovering the core causing fuel temperature to rise.
At 7:25 a.m.,
the LPCS pump problem was fixed and the pump was started.
The large amount of cold water injected by the LPCS system on the hot fuel caused thermal stress resulting in cladding damage.
The LPCS pump returned reactor level to above Top of Active Fuel.
At about 9;00 a.m.,
a shift change was conducted and the exercise was terminated at about 10:00 H
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Federal Observers 6.
Six NRC inspectors evaluated the licensee's response to the scenario.
Inspectors were stationed in the Control Room/Simulator (CR), Technical Support Center (TSC), Operational Support Center (OSC),
and in the Emergency Operations Facility (EOF).
An inspector in the OSC also accompanied an inplant response team.
Exercise Observations MC 82301 7.
The following observations, as appropriate, are intended to be suggestions for improving the emergency preparedness program.
An exercise weakness is a finding identified as needing corrective action in accordance with 10 CFR 50, Appendix E, Paragraph IV.F.5.
All exercise times and other times indicated. in this report are Pacific Standard Time (PST).
Contr'ol Room Simulator CR Thh following aspects of CR operations were observed during the exercise:
detection and classification of emergency events, notification, frequent use of. emergency procedures, and innovative attempts to mitigate the accident.
The inspector assessed'he performance:of the staff as they operated the plant referenced simulator.
The staff was one operating crew.
The inspector also observed the critiques conducted after the exercise by drill participants and licensee staff.
The event began at 3:40 a.m. with the Reactor Core Isolation Cooling (RCIC) turbine operating for a surveillance.
An earthquake caused a
rupture disc to fail on the RCIC turbine exhaust line and caused a loss
. of Division 2 Alternating Current (AC) power.
The RCIC turbine tripped and should have isolated, but failed to do so due to valve failures.
The shift manager assumed duties-as the Plant Emergency Director (PED)
and declared an Alert.
At 4:52 a.m.,
the Plant Manager assumed duties as the PED in the Technical Support Center (TSC).
Approximately three hours after the initial earthquake, an after shock caused a loss of offsite power.
The main turbine tripped and the reactor automatically scrammed with six control rods failing to insert.
The RCIC steam supply line ruptured causing a release to the environment via the operating train of the Standby Gas Treatment System (SGTS).
The High Pressure Core Spray (HPCS) diesel oversped and multiple failures disabled the Residual Heat Removal (RHR) "A" pump and the Low Pressure Core Spray (LPCS)
pump.
This disabled all Emergency Core Cooling Systems (ECCS)
pumps and the Reactor Pressure Vessel (RPV) level fell to below the indicating range, uncovering the core.
The crew emergency depressurized the RPV due to multiple Area Radiation Monitor Alarms (ARM).
The crew recommended to the TSC an emergency classification upgrade to a General Emergency based on a failure of the RPV and Containment and a possible failure of the fuel clad.
At 7:25 p.m., the LPCS pump was enabled and the crew raised RPV level to regain core cooling.
The exercise was terminated at 9:50 a.m.
in the Simulato f l'
I'<
II j
'The
'a ~
b.
C.
inspector observed three areas of minor concern.
Plant Procedure Manual (PPH) 1.3. 1,
"Conduct of Operation," at section 5.2.6, required that the on duty Shift Support Supervisor (SSS)
be the Fire Brigade Leader (FBL).
Contrary to this requirement, during the exercise an Equipment Operator (EO) was assigned duties as the FBL.
Interviews with operators revealed that for actual Control Room manning, the on duty SSS was not the FBL for any normal operating shift.
The FBL for normal operating shifts were designated EOs.
The inspector concluded that this was not in accordance with procedure.
PPH 1.2.3,
"Use of Controlled Plant Procedures,"
section 5. 1. 1 stated
"STRICT ADHERENCE to procedures is our standard to operate...the plant."
The licensee acknowledged this and committed to change PPH 1.3. 1 to reflect an EO as the'BL.
'he crew deviated from the Emergency Operating Procedures (EOP)
without properly declaring a deviation authorized by 10 CFR 50.54(x).
This was contrary to PPH 1.3. 1, section 5. 12.3. 1(d).
CFR 50.54(x) allowed for deviation from the.EOPs under certain conditions.
The ins'pector concluded these conditions were met and the deviation was justified.
The deviation was using the Standby Liquid Control (SLC) system to raise RPV level when level was below 'the indicating range and multiple control rods had failed to insert.
The crew was using EOP 5. 1.6
"RPV Flooding ATWS" and referring to Table 9 of this procedure.
Table 9 did not provide for this source of injection.
The inspector concluded that plant conditions at the time, with a train of SLC available to inject and not in use, made the decision to inject with SLC appropriate.
However the crew did not make attempts to inform plant management or the NRC either before'r after the deviation.
The deviation
'was not properly documented in appropriate logs.
The licensee facility evaluators commented on this during the post exercise critique.
Members of the Training Department. stated that it was management's expectation for crews to strictly adhere to the EOPs.
The licensee indicated they would review the technical basis for exclusion of SLC as a source of core cooling in the circumstances mentioned above.
The crew was remediated by licensee training personnel, regarding management expectations for adherence to procedures and on the use of 10 CFR 50.54(x).
The shift management did not make clear announcements of emergency classification to the operating crew at the time of event declaration.
The shift=management also did'ot make clear announcements of assumption of PED duties to the operating crew.
This caused initial confusion among the board operators as evidenced by frequent questions concerning event classification asked by the board operators to shift managemen f lt I
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The above concerns were considered minor in nature and the inspector concluded overall that the crew effectively mitigated the event, given scenario restrictions, and effectively implemented the emergency plan.
8.
Technical Su ort Center TSC The inspector observed the following aspects of TSC operations:
activation, accident assessment/classification, notification, and interactions between the various emergency response facilities.
The inspector had the following observations in the TSC.
a
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TSC staff manning achieved minimum complement 82.minutes after the declaration of an alert, which exceeded the 60 minute requirement of the Emergency Plan.
The failure to meet minimum TSC staffing requirements in 60 minutes is an exercise weakness (50-397/93-02-01).
'
At 4:46 a.m.,
62 minutes after the Shift Manager declared an alert due to fire in vital switchgear, the Plant Emergency Director (PED) declared the TSC activated with less than the minimum TSC staff compliment identified in the Emergency Plan (EP 4.3. 1. 10)
and Plant Procedures (PPM 13. 10.3.6).
The PED declared the TSC activated with less than the minimum complement because, at that time
.the event did not require the technical skills of the missihg individual and the control room Shift Technical Advisor (STA) could fill the functional requirements.
The PED's reasoning appeared weak because the STA had specific control room responsibilities that would have competed with the TSC core/hydraulics assessment function.
Emergency workers were sent into a plant area that was simulated Co have significant radioiodine inventory, but were not administered Potassium Iodide (KI) as a precautionary measure.
The failure to administer KI under adverse radiological conditions is an exercise weakness (50-397/93-02-02).
At 7:04 a.m.,
due to core uncovery and subsequent fuel failure and an unisolable steam leak in the reactor building (RB), radiation levels in the RB increased.
The RB equivalent radioiodine levels reached IE-2 microcuries per cubic centimeter (uCi/cc)
by approximately 7:30 a.m.
The TSC, specifically the Radiation Protection Manager, understood area radiation levels in the RB had significantly increased, but did not recognize radioiodine levels, had increased because no one had directed sampling the RB-atmosphere.
Plant Procedure PPH 13. 14. 1.C,
"Emergency Exposure Measures/Protective Action Guides," states the RPH and the PED consult if radionuclide concentrations are greater than 1E-7 uCi/cc to access whether or not emergency workers within the protected area should take KI. Drill logs indicate that the
to determine what data was current.
Specifically, the PSB data for off-site release was annotated once and never updated.
The turnover between the off-going and on-coming PEDs generally contained the appropriate information, but lacked focus and emphasis on the simulated threat to the general public and on-site personnel.
The turnover did not discuss doses at the site boundary or in the RB.
The turnover did not sufficiently discuss the status of the TSC/OSC priority actions.
The PEDs'urnover lacked the rigor generally seen in a Shift Managers'urnover which has a log that provides a chronology of events and status of significant items to follow during the next shift.
9.
0 erational Su ort Center OSC The following aspects of OSC operations were observed:
activation of the OSC, functional capabilities, communications, OSC habitability, and moni't'oring of task teams.
The; OSC was activated and staffed in an orderly and timely manner, however, the inspector had the following observations:
Public Address (PA) system exercise announcements were difficult to hear during the initial stages.
Licensee personnel explained that this communications problem was related to hardware problems that were specific to the exercise PA system.
b; C.
The OSC Director declared the OSC activated before electrical craft logged into the OSC accountability log.
Plant procedure PPM 13. 10.9,
"Operations Support Center Director and Staff Duties,"
noted in part that electrical craft were needed in order to declare the OSC adequately staffed for activation.
PPM 13. 10. 10,
'"Health Physics (HP), Chemistry and, Maintenance Support Duties,"
required in part that personnel responding to an Alert log themselves in the accountability log.
The OSC Director was asked about his awareness of the available OSC personnel prior to his declaration of OSC activation,
,He stated that he knew which personnel were in the OSC vicinity, including electrical crafts, and he did not depend on whether those individuals had signed in.
It was noted that the OSC Director encouraged all OSC personnel to log in.
It was noted that OSC radiation monitors and airborne radioactivity samplers were operating in accordance with PPM 13. 10.9 requirements for initiating OSC habitability monitoring.
The inspector did not observe any HP Technicians collecting data from the OSC radiation monitors, however, two HP Technicians explained their monitoring activities to the inspector.
Although the exercise objectives called for HP Technicians to demonstrate the ability to monitor OSC habitability, there was no exercise scenario radiological data for the OSC area and General
consultation between the PED and the RPH may not have occurred.
The drill logs indicate the RPH and OSO Director, and the PED and the OSC Director discussed exposure to emergency workers and the potential administration of KI.
At approximately 8:30 'a.m.
and at 9:00 a.m.
the Operations Support Center (OSC) director dispatched team's of emergency workers to the RB.
The atmosphere in the RCB had a radioiodine equivalent of IE-2 uCi/cc, which represented a
significant potential thyroid dose.
The team members, who were equipped with SCBAs, had not been administered KI as a
precautionary measure.
Following the drill the RPM stated he had recognized the RB had elevated radiation levels but recommended against administering KI because the RB was isolated, the standby gas treatment system (SGTS)
was functioning, only 0. IN fuel failure had been estimated and emergency workers would be wearing self contained breathing apparatuses (SCBAs) while in the RB.
PPH 13. 14. 1 requires that KI be taken by emergency workers even if they are wearing the respirators.
The RPH's reasoning to dispatch emergency radiation workers into the RB without administering KI appeared weak because no RB air samples had been taken to assess the potential threat to the workers and inappropriate reliance was placed on the protection factor of the SCBA.
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The TSC staff performed prompt, accurate, accident assessment and notifications'he TSC staff assessments and notifications agreed with and were coincident with the EOF staffs'ssessments and notifications.
TSC and other emergency centers'nteractions were generally
'adequate.
The interaction between the OSC and the TSC required strengthening.
Ineffective communication of expectations with respect to obtaining and reporting of RB radionuclide levels contributed to the PED and RPH not thoroughly assessing the administration of KI, and the OSC Director's confusion as to when radioactivity was released during the event.
Toward the conclusion of the drill, the TSC staff recognized a
disparity between the length of time the core had been completely uncovered, the absence of hydrogen generation, the drywell radiation levels and the estimated core damage.
The TSC staff discussed the disparity with the drill controllers; however, the disparity was not resolved.
The disparity between core damage, radiation levels and hydrogen generation was a scenario problem.
The inspector observed that all the TSC status boards with the exception of the Plant Status Board (PSB)
had been adequately maintained.
Selected information on the PSB was updated; however, the time of the updates was not recorded, which made it difficult
t
d.
Service Building that challenged HP Technicians'SC habitability assessments.
The inspector noted from exercise data that the OSC airborne radioactivity increased to 140 counts per minute'(cpm),
but no habitability assessment concern had been raised by HP.
Licensee personnel maintained that exercise objective was demonstrated by HP Technicians performing OSC surveys.
The inspector concluded that this observation was a scenario related problem.
The inspector noted that neither personnel in the OSC, nor OSC Task Teams were administered KI tablets during the exercise.
The inspector was,not aware of any conversations in the OSC between the Lead HP Technician and the OSC Director regarding KI, however, the Radiation Protection Hanager stated that he and the Lead HP Technician had discussed the matter.
During the exercise, the potential for imminent core damage, and
the unmonitored radioiodine releases from the RCIC system into the Reactor Building did not lead to the administration of KI tablets in accordance with PPH 13.14. 1,
"Emergency Exposure Levels/Protective Action Guide1ines,"
which required in part that the RPH recommend that emergency workers in the OSC and other areas take KI:
'I
~
When radioiodine concentrations were known, projected, or expected to exceed 1.4E-7 uCi/cc, or if the release was from an unmonitored source known to contain radioiodine.
'
As directed by the RPN for respective areas, personnel shall use respirators in addition to KI for thyroid protection.
The circumstances of this observation are further discussed in section 8.b above.
.The inspector made the following observations regarding emergency recovery teams that were dispatched from the OSC.
The exercise scenario did not anticipate that OSC Task Team ¹2, which was dispatched to close RCIC steam supply valve ¹8 would be in the immediate vicinity when the scenario caused a RCIC steam line break.
The inspector concluded that OSC Team ¹2 should have been considered exercise scenario casualties for personnel recovery and rescue.
The inspector found that OSC Team ¹2 had received minimal exposure and contamination when they reported back to the OSC, which should have been unlikely under the scenario.
This observation appeared to be a scenario related problem.
When OSC Task Team ¹8 asked the Lead OSC HP about establishing contamination stepoff pads for their operation, the Lead OSC HP directed them to establish an imaginary stepoff pad in the Reactor
Building/Turbine Building airlock.
Consequently, OSC Team ¹8 mistakenly established an imaginary stepoff pad in the Turbine Building.
The inspector attributed Team ¹8's mistake to the instructions given by the OSC Lead HP.
Contamination stepoff pad activities are typically not simulated during exercises, but actually performed.
. The inspector concluded that this observation was a performance based error.
The OSC Lead HP Technician asked the OSC Team ¹8 HP Technician to retrieve an air filter sample that would have been too radiologically hot to handle safely.
The RPM agreed with the inspector's observation, and further added that the Lead OSC HP Technician should have assigned another OSC HP Technician for such a specific task.
Although the exercise terminated before the OSC Team ¹8 HP Technician could recover the air filter, the HP Technician told the inspector that he had not really considered the potential radiological consequences.
This observation did not actually result in a performance based error by the HP Technician, but it did represent a chance for the radiation protection group to re-assert 'its expectations; The OSC Team ¹8 suggested that all. team members test their self-contained breathing apparatus (SCBA) prior to entering the Reactor Buil'ding.
Before entering the Reactor Building, the OSC Team ¹8 Lead HP Technician discovered that his air supply was leaking, but he did not change his air bottle.
Consequently, his one hour SCBA air supply only lasted 20 minutes, which made it necessary for the HP Technician and all of Team ¹8.to evacuate prematurely and before their task was complete.
Licensee procedure PPM 11.2. 11.4,
"Use of Respirator Protection Equipment," section for SCBAs requires in'part that if respirator equipment is unsatisfactory, return equipment to issue point, inform HP personnel of the
" problem, and obtain different equipment.
The RPM concurred that the HP Technician did not meet the expectation of the licensee's radiation protection program.
This observation appeared to be a
performance based problem.,
The inspector observed the effectiveness of radio communications'etween OSC Team ¹8 members and the OSC.
OSC Team ¹8's hand held radios seemed awkward when used with SCBAs.
Many repeats of information were necessary, which were due to the type of radio transmission and receiver system being used.
Team ¹8 members had to place the radio up to the SCBA face mask, apply considerable pressure, and shout to be heard.
This form of communication seemed ineffective, and the method for assuring communications appeared to challenge the integrity of the SCBA face seal.
The inspector concluded that licensee's field team radio communication system did not appear completely reliable or functional'
radio communication exchange between OSC Team ¹8 and the OSC Maintenance Leader at 9:30 a.m.,
seemed to highlight the difficulty in effective communications.
The OSC Team ¹8 Leader
had to repeat and explain his message several times concerning the status of their recovery operation.
The OSC Team ¹8 Leader was trying to determine if it was necessary for Team ¹8 to re-enter the Reactor Building. in order to complete the task, or whether the OSC should send a backup team.
After shift change, the new OSC Director was not fully aware that Team ¹8 was in the Reactor Building; because the shift turnover he received was apparently not thorough.
Additionally, the RPH revealed that OSC Team ¹8 was not supposed to re-enter the Reactor Building when in fact they did.
The inspector considered this observation as a performance based concern related to an ineffective OSC shift turnover.
10.
Emer enc 0 erations Facilit EOF Two inspectors were located in the EOF during the exercise.
One was primarily observing activities in the EOF.Communications Center and the EOF Decision Center.
The other was primarily observing activities in the'Meteorological and Dose Assessment Center (MUDAC) and the Technical Data Center (TDC).
The following EOF operations were observed:
activation; functional capabilities; interface with offsite officials; dose assessment; and the formulation of protective action recommendations.
The following are NRC observations of EOF activities.
a
~
Decision Center and Communications Center (1)
The EOF was activated 70 minutes after the declaration of an ALERT.
The essential personnel as defined by Figure 4-3 of the licensee's Emergency Plan were available about
minutes earlier but activation was delayed because no Field Team Coordinator had arrived.
A Field Team Coordinator arrived about 107 minutes after the event was declared.
b.
- (2)
Command and control in the EOF was effectively demonstrated.
(3)
Notification of offsite agencies was performed in a prompt manner.
(4)
Protective Action Recommendations were made appropriately by the licensee in accordance with NRC guidance.
(5)
A minor amount of prestaging was apparent prior to the exercise.
Earphones, which monitor "Crash" telephone lines had been prepositioned.
Position nameplates were also prepositioned.
(6)
The inspector noted that no scenario details were discussed at the post-exercise critique.
The inspector has observed, at other facilities, that this practice contributes to improving the critiques and offered this as an observation for improvement.
MUDAC and TDC
i
( 1)
Inade uate Cored Dama e Assessment.
(See also section 8. b above)
The TDC underestimated the damage to the core by a
factor of about 30.
The TDC staff used PPM 9.3.22 and
=
concluded that a potential of 0. 1 percent of core damage existed when in fact the water level harl dropped below -192 inches and reached-310 inches for over twenty minutes (between 7:05 a.m.
and 7:30 a.m.)
The TDC staff used Section 5.2. 1 of PPM 9.3.22 for their assessment.
Section 5.2. 1 uses a correlation between containment radiation monitors CM S-RE-27A and B and percent core damage.
While the scenario failed to provide hydrogen concentration levels consistent with the damage sustained by the cladding, other in-plant radiation levels were not used to reconcile the apparent inconsistency in the level of core damage.
(2)
Few Attem ts Were Made to Antici ate and Evaluate the Potential Conse uences of Losin the Standb Gas Treatment
Th hlldhtdtd <<1 t
"ht if" scenarios to determine offsite doses if the SGTS would become unavailable.
The unisolable RCIC steam line break had created a direct path for radioactive materials to the Reactor Building and through the SGTS into the environment.
'011 hh
. (a)
One field team reported an iodine reading higher than the scenario called for.
One of the MUDAC controllers/evaluators intervened and corrected the data.
This correction, however, did not get to the dose assessment group; which performed a calculation based on the erroneous data.
(b)
One evaluator appeared to get involved with the players.
Evaluators should not assist or prompt players unless the exercise progression requires such intervention, Licensee Criti ues A series of exercise critiques was conducted by the licensee upon completion of the exercise.
a.
Facility critiques were conducted at each emergency response facility with players and controllers immediately following the exercise.
The licensee had noted several of the items also identified by the NRC observers, as well as other exercise strengths and problems for improvement.
The facility critiques appeared satisfactory and appropriate to exercise activities; however the team noted there is room for improvement (e.g.,
the scenario was not reviewed with players, items identified by NRC observers were not indicated by licensee observers, etc.).
b.
The licensee provided a corporate level critique for the NRC inspection team on February 25, 1993.
The corporate critique did not appear fully satisfactory and appropriate to exercise activities, because objectives were not fully met as appeared to the inspectors to be implied in the critique.
While one of the exercise weakness'es was partially discussed in the critique, the other was not recognized or discussed.
12.
Onsite Followu of Events at 0 eratin Power Reactors HC 93702 Two unusual events (UE) had been reported to the NRC Headquarters Operations Officer (HOO) since the last routine emergency preparedness inspection at WNP-2.
(See Section 2.f. above, Inspection Followup Item 92-AH-OI, HOO Event Number 24420)
b.
At 5:50 p.m.
(PST)
on February 10, 1993, the licensee declared an Unusual Event when a steam leak from a reactor feed pump (RFP)
resulted in a loss of the RFP and a reactor scram on low reactor vessel water level.
Local offsite agency notifications were made within three minutes.
Notification to the NRC was made about
minutes later.
The event was terminated at 7:05 p.m.
when an inspegtion of the RFP confirmed that the steam leak was isolated.
In each of the above events, a review of the circumstances and documentation pertaining thereto indicated that the event classifications appeared appropriate and that timely'otifications and follow-up notifications were made to the county and state agencies and to the NRC.
13.
Exit Interview.
On February 25, 1993, at the conclusion of the site visit, the inspectors met with the licensee representatives identified in theattachment hereto to summarize the scope and the preliminary results of this inspection.
The inspectors noted those previous open exercise i.tems which would be closed and new items identified for future review.
The inspectors
'reviewed the weaknesses discussed in section 8 above.
ATTACHMENT Exit Meeting Attendee l
M. H. Ace, WPPSS H. L. Aeschliman, WPPSS D. A. Armstrong, WPPSS P.
T. Bagan, WPPSS H. L. Baird, WPPSS J.
W. Baker, WPPSS R.
C. Barr, NRC P.
E. Bentrup, WPPSS G. A. Block, MPPSS R. A. Bresnahan, WPPSS J.
D. Carpenter, WPPSS L. C. Carson, NRC T.
E.
Chapman, MPPSS T.
E. Chrisler, WPPSS H.
R.
Chunn,.
WPPSS A. H. Clark; WPPSS A. J.
Connor, MPPSS I.
E.
Day',
G.
Embree, WPPSS J.
D. fisher, WPPSS N.
L. Garza, WPPSS;.
J.
C. Gearhart, WPPSS ATTACHMENT NRC EXIT INTERVIEW ATTENDEES A. D. Hcgueen, NRC K.
P.
Meehan, WPPSS A. S. Hohseni, NRC M. M. Monopoli, WPPSS L. S. Morris, WPPSS C.
R. Noyes, WPPSS A. L. Oxsen, WPPSS J.
V. Parrish, WPPSS R. J.
Pate, NRC D. J. Pisarcik, WPPSS P.
M. squalls",
NRC F.
D. quinn, MPPSS L. A. Rathbun, WPPSS J. J. Russell, NRC G.
C. Sorensen, WPPSS C.
N. Stroh, WPPSS P.
H. Taylor, WPPSS J.
D. Teachman, WPPSS R.
L. Utter, WPPSS W.
W. Waddel, WPPSS R.
L. Webring, WPPSS P. 0. Yonts, WPPSS R. J.
G.
H.
J.
D.
S. J.
J.
M.
Given, MPPSS Godfrey, WPPSS Harmon, MPPSS Haynes, WPPSS Hogg, WPPSS D.
B. Holmes, WPPSS W. A. Kiel, WPPSS.
D.
L.
R.
L.
D.
B.
D.
E.
J.
K.
King, MPPSS Koenigs, WPPSS Krieg, WPPSS Larson, WPPSS Lovejoy, WPPSS
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