IR 05000461/1998027
| ML20199B624 | |
| Person / Time | |
|---|---|
| Site: | Clinton  |
| Issue date: | 12/31/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20199B622 | List: |
| References | |
| 50-461-98-27, NUDOCS 9901140004 | |
| Download: ML20199B624 (22) | |
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U.S. NUCLEAR REGULATORY COMMISSION
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REGIONlli l
Docket No:
50-461 License No:
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Report No:
50-461/98027(DRS)
Licensee:
lilinois Power Company
Facility:
Clinton Power Station
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Location:
Route 54 West
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Clinton,IL 61727
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Dates:
November 17-20,1998 i
inspectors:
J. Foster, Sr. Emergency Preparedness Analyst T. Ploski, Sr. Incident Response Coordinator D. Funk, Emergency Preparedness Analyst J. Kreh, Radiation Specialist, Ril K. Stoedter, Resident inspector C. Brown, Resident inspector Approved by:
James R. Creed, Chief, Plant Support Branch 1 Division of Reactor Safety
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9901140004 981231 i
PDR ADOCK 05000461
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EXECUTIVE SUMMARY Clinton Nuclear Power Station NRC Inspection Report 50-461/98027
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This inspection consisted of evaluating the licensee's performance during an exercise of the
. Emergency Pian. It was wnducted by four regional ernergency preparedness inspectors and two resident inspectors. No violations of NRC requirements were identified. Two Exercise Weaknesses were identified related to (1) priority establishment in the TSC, and (2) Protective Action Recommendations (PARS).
Plant Support Overall licensee performance during the 1998 emergency preparedness exercise was o-adequate and licensee emergency plan implementation activities met regulatory requirements. Two Exercise Weaknesses were identified. (Section P4.1.b.2).
I Overall performance in the Simulator Main Control Room (SMCR) was adequate. During e
the rapidly moving exercise scenario, control room shift personnel properly diagnosed reactor events at the Notification of Unusual Event, Alert, and Site Area Emergency classification levels. Notifications were promptly made to offsite officials. (Section P4.1.b.1)
Deficiencies in emergency operating procedure (EOP) implementation were identified.
e Specifically, operations personnel failed to start the hydrogen - oxygen monitors until 40 minutes after entering EOP-6, " Primary Containment Control." In addition, operations personnel did not determine whether a valid entry condition into EOP-9, " Radioactivity Release Control," existed. Problems with EOP implementation were considered significant since similar concems were also identified during an emergency preparedness drill performed in October 1998. (Section P4.1.b.1)
e An operator error in the SMCR resuited in the isolation of the Reactor Core isolation CooCng system, the only source of cooling water for the reactor at the time. (Section P4.1.b.1)
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The Technical Support Center (TSC) staff's performance was adequate. Plant event
. analysis, event classification, notifications, briefings, and communications with other facilities were competently performed by the staff. (Section P4.1.b.2)
The transfer of command authority from the SMCR decision maker to the TSC decision l
e maker did not occur until 56 minutes after the Alert declaration. Delay of activation until field monitoring teams were in place was unnecessary. (Section P4.1 b.2)
One Exercise Weakness was identified conceming the TSC staff's setting of priorities for
' Operations Support Center (OSC) tasks. A " Priority 1" designation was used for approximately half of the OSC teams. At one point, the inspectors noted that 6 of 10 assigned OSC tasks / teams were designated as " Priority 1." Th!s resulted in inefficient
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use of resources on the most critically important tasks. Also, a sense of urgency was not exhibited when repair teams were briefed and dispatched from the OSC.
(Section P4.1.b.2)
One Exercise Weakness was identified concerning protective action recommendations e
(PARS). The initial PAR transmitted to State representatives upon declaration of a General Emergency did not advise that persons in the non-evacuated portion of the Emergency Planning Zone should go indoors to monitor Emergency Alert System broadcasts, although this was the default minimum PAR listed in the licensee's procedures. An unclear PAR revision was subsequently issued by the Emergency Operations Facility (EOF) staff and was eventually corrected before the exercise was terminated. (Section P4.1.b.2)
A backup power supply ceased powering the TSC Public Address (PA) system after 26
minutes of operation. The loss cf the PA system meant that TSC managers' briefings were not audib'e in the OSC. An available megaphone was not utilized. (Section P4.1.b.2)
Overall performance of OSC management and staff was mixed, with examples of both e
good and poor individual performance. Overall command and control of the facility was insufficient. The OSC management did not maintain good awareness of deployed teams' progress or results. The OSC Director seldom stayed in the command area of the OSC where teams' reports were being received so that these reports could promptly be assessed and an overall perspective of deployed teams' activities could be maintained. (Section P4.1.b.3)
The OSC team briefings followed the same guidelines for high priority tasks as for lower e
priority tasks. There were no apparent management expectations for briefing and dispatching higher priority teams from the OSC more expeditiously than lower priority teams. (Section P.4.1.b.3)
The EOF protective measures staff was unable to completely respond to the Emergency e
Manager's and s!mulated NRC responders' requests for several offsite dose projections in a timely manner. (Section P4.1.b.4)
e A modem on the computer assigned to the EOF protective measures staff actually failed and the staff was unaware that an available backup computer also had an installed modem. (Section P4.1.b.4)
Self-critiques following termination of the exercise were critical and included inputs from
controllers and exercise participants, in particular, the SMCR evaluators critically assessed operator performance. (Section P4.1.b.6)
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l Raport Detalla IV. Plant Support P3 Emergency Preparedness Procedures and Documentation P3.1 Review of Exercise Obiectives and Scenario (82302)
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The inspectors reviewed the 1998 exercise's objectives and scenario and determined
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that the exercise would acceptably test major elements of the licensee's emergency plan. The scenario provided a challenging framework to support demonstration of the licensee's capabilities to implement its emergency plan. The scenario included a radiological release and several equipment failures.
P4 Staff Knowledge and Performance in Emergency Preparedness P4.1 1998 Evaluated Biennial Emeraency Preoaredness Exercise a.
Inspection Scope (82301)
Appendix E to 10 CFR Part 50 requires that power reactor licenseos conduct exercises that involve participation by offsite authorities biennially. On November 18,1998, the licensee conducted a biennial exercise involving full participation by State of Illinois and DeWitt county responders. This exercise was conducted to test major portions of the licensee's onsite and offsite emergency response capabilities. Onsite and offsite emergency response organizations and emergency response facilities were activated.
The inspectors evaluated performance in the following emergency response facilities:
Simulator Main Control Room (SMCR)
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Technical Support Center (TSC)
o Operations Support Center (OSC)
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e Emergency Operations Facility (EOF)
The inspectors assessed the licensee's recognition of abnormal plant conditions, classification of emergency conditions, notification of offsite agencies, development of j
protective action recommendations, command-and-control, the transfer of emergency responsibilities between facilities, communications, and the overall implementation of the emergency plan. In addition, the inspectors attended the post-exercise critiques in each of the above facilities to evaluate the licensee's initial self-assessment of exercise performance.
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Emercency Resoonse Facility Observations and Findinas b.1 Simulator Main Control Room (SMCR)
Overall licensee performance in the SMCR was adequate. During the rapidly moving exercise scenario, SMCR personnel properly diagnosed reactor events at the Notification of Unusual Event, Alert, and Site Area Emergency (SAE) classification levels.
Event notification forms and verbal notifications to State of Illinois officials and the NRC were completed in a detailed and timely manner. The Shift Manager (SM) made a
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conservative decision in declaring the SAE when he correctly determined that l
l onsite/offsite AC power capability would not be restored within 15 minutes. The SMCR l
communicator did a good job of verifying that information he had provided to State
representatives had been received by requesting repeat back of the information by the
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Communications within the SMCR and between the SMCR and other emergency
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response facilities were not always effective. For example, the Control Room Supervisor i
(CRS) was not aware that there was an injured contaminated worker included in the
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l scenario, while the SM was aware of this situation. Also, communications of station priorities between the SM and Station Emergency Director (SED)in the TSC, were not always in conjunction as to the rank order of the tasks. The CRS and SM held crew
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l briefings and updates when appropriate. These crew briefings kept the crew aware of current plant conditions, but at times lacked information regarding desired goals. The l
SMCR crew generally used effective three-way communications throughout the exercise.
The SMCR crew properly diagnosed each casualty as it occurred; however, mitigation of the casualties was not always effective due to poor command and control and the failure to anticipate equipment problems. For example, more than 10 minutes were needed for i
l the E-area Operator to reach the screenhouse and diagnose the cause of degraded shutdown service water flow. This delay resulted in the SMCR crew failing to initiate a rapid power reduction to correct the degraded flow conditico prior to receiving a reactor scram due to the explosion of the reserve auxiliary transformer.
Continued deficiencies in Emergency Operating Procedure (EOP) implementation were identified. Specifically, the crew failed to start the hydrogen - oxygen monitors until 40 l
minutes after entering EOP-6, " Primary Containment Control," due to other plant o
priorities. The inspectors considered the 40 minute delay to be excessive. Following the exercise, the inspectors questioned the SMCR's lead exercise controllor to determine why the hydrogen - oxygen monitors were not started in a timely manner. The.
inspectors were informed that the monitors were not started due to the need to complete higher priority activities in the SMCR. The inspectors considered the response to be questionable since time was available for the operations crew to evaluate the four
remaining legs of the EOP and to start the hydrogen mixing compressors.
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An additional problem with implementing EOPs occurred when the crew did not request information from the TSC or EOF staffs to determine whether a valid entry condition into
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EOP-9," Radioactivity Release Control," existed. Crew members discussed the fact that
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core damage had likely led to a radioactive release that exceeded the level requiring an l
Alert classification. However, SMCR supervisors did not feel that entry into EOP-9 was
l warranted since one of the actions included in EOP-9 had been completed as part of j
EOP-3, " Emergency RPV [ Reactor Pressure Vessel] Depressurization," and the l
remaining actions were unable to be completed due to the loss of power. Following the
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. exercise, the inspectors questioned the SMCR's exercise controliers and evaluators concerning the missed EOP entry condition and were informed that the SM and the CRS had discussed enteiing EOP-9 approximately 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> after the station blackout had
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occurred. The SM and the CRS did not request TSC staff to provide information f
indicating an abnormal radioactive release. TSC staff did not forward reports indicating L
an abnormal release to SMCR staff. Consequently, SMCR supervisory personnel did not consider entering EOP-9.
. The inspectors considered the aforementioned examples of poor implemer,tation of
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EOPs to be significant, since similar concems were identified during an emergency
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preparedness drill performed in October 1996.
~ At approximately 8:30 a.m., the SMCR crew received the Reactor Core Isolation Cooling (RCIC) steam tunnel timer bypass alarm due to temperatures in the steam tunnel exceeding 156 degrees Fahrenheit. Annunciator response procedure 5063.05,"RCIC Steam Tunnel Timer Bypass," stated that, if the RCIC system is required for safe plant
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shutdown, the SM or CRS should direct operations personnel to bypass the RCIC
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isolation logic within 25 minutes to prevent the isolation of the RCIC system. Although
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the operator manipulating the RCIC system was not specifically directed to bypass the RCIC isolation logic, he was aware that the failure of both emergency diesel generators was imminent due to degraded service water flow and that the failure to bypass the RCIC logic within 25 minutes would result in a RCIC isolation. However, instead of immediately bypassing the logic, the operator became distracted with other activities and failed to bypass the logic within the required time. As a result, the RCIC system isolated at 9:04 a.m., which impacted the mitigation of the station blackout event.
I Due to the loss of power postulated in the scenario, many of the normal SMCR indications were lost. Although the operations crew handled the loss of instrumentation well, one deficiency was identified. The "A" reactor operator noted that the reactor fuel i
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. zone level indication had failed high, and promptly notified the CRS. Due to the perceived instrument failure, the CRS declared that reactor water level was unable to be determined and promptly entered EOP-2,"RPV Flooding." Approximately three minutes later, SMCR personnel observed that the fuel zone level indication was again on scale.
However, instead of considering the fuel zone level instrument to be failed based on previous inaccurate level readings, the CRS declared the fuel zone level instrument to be functional and considered its questionable indication to allow exiting EOP-2 and re-entering EOP-1,"RPV Control".
The transfer of command and control of emergency responsibilities from the SM to the TSC's Site Emergency Director (SED) was orderly,
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b.2 Technical Sucoort Center (TSC)
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Overall, the TSC staff's performance was adequate. The TSC staff performed and
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interacted efficiently and professionally, and clear'y functioned well as a team. However, three-part communications were used sporadically. Some minor errors in the flow of j
information occurred as a result.
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The Alert declaration was announced on the Public Address (PA) system. As a result, personnel began arriving in the TSC within about 7 minutes of the Alert declaration.
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Ultimately, however, the transfer of command authority from the SM to the TSC's SED did not occur until 56 minutes after the Alert declaration. The delay in transferring command authority was due to the SED's following a step of Emergency Plan
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l Implementing Procedure (EPIP) FE-01, "TSC Operations," which specified that field l
teams were key personnel required to be in place before the SED could assume
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l command authority from the SM, who was the interim SED. However, Section 3 of the licensee's Emergency Plan contained no analogous statement. The licensee
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subsequently informed the inspectors that the statement in EPIP FE-01 would be re-evaluated for consistency with the Emergency Plan. Completion of this re-evaluation will i
be tracked by inspection Foliowup Item (IFl 50-461/98027-01 (DRS)).
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The delay in transferring command authority to the SED caused the SM in the SMCR to retain emergency classification, notification, and Protective Action Recommendation (PAR) responsibilities longer than was necessary. As a direct result, declaration of the Site Area Emergency occurred in the SMCR rather than in the TSC contrary to the scenario developers' expectation.
The SED's declaration of a General Emergency (GE) at 9:48 a.m. was appropriate.
l However, the associated PAR transmitted via the State of Illinois' Nuclear Accident l
Reporting System (NARS) message number 4 was not in accordance with the licensee's procedures. According to EPIP RA-02," Protective Action Recommendations," the default (minimum) PAR for a GE is to "Evacuals 0-2 mile radius and 2-5 miles downwind unless conditions make evacuation dangerous and advise the remainder of plume
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Emeroency Plannina Zone (EPZ) to ao indoors to monitor EAS IEmeroency Alert Systeml broadcasts [ emphasis added)"(from Attachment 1, Protective Action Chart).
However, NARS message number 4 did not specify any PARS beyond 5 miles. The TSC staff's failure to issue the appropriate default PAR upon declaration of the GE combined with the EOF staff's subsequent PAR decision making difficulties (summarized in Section P4.1.b.4 of this inspection Report) was considered an Exercise Weakness the resolution
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of which will be tracked by inspection Followup item (IFl 50-461/98027-02(DRS)).
The TSC staff's assignment of priorities for OSC tasks entailed using " Priority 1" for approximately half of the OSC teams. At one point, the inspectors noted that 6 of 10 assigned OSC tasks / teams were designated as " Priority 1." This resulted in inefficient use of resources on the most critically important tasks. For example, a sense of urgency was not exhibited when repair teams were dispatched from the OSC. The designation of many teams as " Priority 1" would not be a tenable approach if personnel resources were limited, such as in the early stages of an off-hour event. The TSC staff's difficulty in
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prioritizing teams along with the lack of a sense of urgency in dispatching high priority f
teams from the OSC (summarized in Section P4.1.b.3 of this report) was considered an
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. Exercise Weakness. The licensee's actions to address this weakness will be tracked as j
Inspection Followup item (IFI) 50-461/98027-03(DRS).
Command and contro; of TSC operations by the SED was otherwise effective. The SED
. briefed TSC staff when plant conditions changed and conducted periodic round table (or j
" table head") discussions that facilitated the sharing of information among key TSC i
personnel.' Periodic briefings, heard via a public address system throughout the TSC r
and in the OSC, further facilitated the flow and exchange of plant status information.
Plant conditions were continuously monitored and primary plant parsmeters were
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displayed on TSC status boards, which were generally well maintained i
i As the scenario postulated a loss of power affecting the TSC, and since problems had
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previously been identified related to power supplies in the licensee's emergency j-response facilities, during this exercise the inspectors requested that exercise controllers i-modify the scenario to exercise use of the backup power supply to the PA system. The
backup power supply ceased powering the PA system after 26 minutes of operation.
l The loss of the PA system meant that TSC briefings were also not audible in the
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adjacent OSC. An available megaphone was not utilized. Resolution of this issue will be
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tracked as an Inspection Followup item (IFl 50-461/98027-04(DRS)).
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j The material condition of the TSC was considered poor, which was also noted in
Inspection Report No'. 50-461/98025(DRS). For example, conduits and wiring presented a considerable tripping hazard. The TSC's Area Radiation / Process Radiation panel was
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out-of-service pending system modifications.
b.3 - Operations Supoort Center (OSC) and Emeroency Response Teams The overall performanco of OSC management and staff was mixed, with examples of both good and poor individual performance.
The OSC was fully staffed and operational in a timely manner following the Alert declaration. After some initial confusion, status boards were adequately maintained and used to track personnel in each technical discipline who were available for assignment to emergency response teams. Provisions for issuing dosimetry and establishing dose limits were effective.
The initial sign-in process and use of the OSC technicians'" holding area" were effective.
However, the inspectors did not observe any personnel donning anti-contamination clothing or collecting other equipment in preparation for being sent out on an emergency response team. Technicians waited until being selected for a team before preparing to perform their duties rather then preparing beforehand, which should have shortened team dispatch times. Noise levels within the OSC were maintained acceptably low.
- As indicated in Section P4.1.b.2 of this inspection report, inspe; tors within the OSC noted that there were multiple " Priority 1" teams assigned by TSC staff. The inspectors
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s inquired why more than a single team was designated " Priority 1 " In response the OSC
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Director stated that all teams would be " Priority 1" unless there was a shortage of personnel to staff the teams. The inspectors observed that pre-deployment team briefings within the OSC followed the same guidelines regardless of the relative priorities assigned to the teams by TSC staff. Based on discussion with the licensee's emergency preparedness staff following the exercise, the inspectors determined that there were no j
apparent management expectations for briefing and dispatching higher priority teams more expeditiously than lower priority teams. As indicated in Section P4.1.b.2 of this report, the licensee's difficulties in prioritizing teams and the associated lack of a sense of urgency in dispatching teams from the OSC was considered to be an Exercise Weakness.
The teams' briefings included current information on relevant, simulated radiological conditions. Team leaders were designated and radiation protection personnel were assigned as appropriate. The teams were dispatched after completing radio communication checks on the hand-held radios.
Response teams were dispatched from between 9 and 44 minutes of TSC managers'
requests. Teams were adequately debriefed and were asked to report any unexpected conditions encountered. Briefings and debriefings were documented on forms provided
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according to procedures.
Overall command and control within the OSC was insufficient. Management in the OSC was not continually aware of response teams' progress or results. The inspectors
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observed that the OSC communicator was frequently the only person in the OSC that knew the current status of the emergency response teams. This communicator obtained the information and logged it properly; however, the OSC Director was frequently not in the immediate vicinity of the communicator, which resulted in the incoming information flow stopping at the communicator without getting onto the status boards or being passed on to TSO, EOF, or SMCR staffs. When not near the communicator, the OSC Director moved around the OSC and was engaged in one-on-one conversations.
Although the OSC Director consulted with the communicator to ascertain the emergency response teams' current status, these consultations were usually interrupted by communications from the field. Consequently, the director's attention was usually narrowly focused on the communicator, or on a small group, or on a conversation, rather than on maintaining an overall perspective.
The OSC Director's absence from the OSC's " command area" directly contributed to the loss of early information that the Reserve Auxiliary Transformer (RAT) had not been sabotaged. Having lost this information, response team number 8 was formea, more than two hours later, to investigate if the RAT explosion had been due to sabotage.
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Another example of a lack of effective management oversight within the OSC involved a team assigned to attempt to restore cooling water flow. This team had to wait for more than an hour for a safety technician so that a confined space entry could be accomplished.
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The inspectors observed that the use of three-part communications within the OSC was sporadic. Few directions and limited information were either given or received utilizing good ccmmunication techniques. Most information and directions were communicated in a conversational manner with !ittle, if any, repeat backs to ensure accuracy.
b,4 Emeraency Ooerations Facility (EOF)
The EOF staff's overall performance was adequate. Per procedures, approximately 25 staff reported to the EOF within 15 minutes of the Alert declaration. These personnel included some protective measures staff members, an engineering supervisor, Emergency Action Level (EAL) advisors, security staff, administrative support staff,
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status board plotters, and warehousemen.
Protective measures staff consisted of technicians who were formed into three tud (offsSe monitoring) teams plus those responsible for directing the field teams' activities and e ssessing their reports. Following an initial briefing, field team members obtained appropriate dosimetry and thoroughly checked their equipment (previously pre-staged in large cases). Survey instruments removed from these cases, as well as spares maintained in the EOF's decontamination room, had stickers indicating that these instruments were within their calibration period. Following a more detailed briefing on current plant conditions, response priorities, weather conditions, and the initial deployment strategy, the three field teams left the building to complete their communications equipment tests within an acceptable 50 minutes of team members'
arrivals in the EOF.
The remainder of the EOF staff arrived shortly after the Site Area Emergency declaration. As was the case with their predecessors, these incoming personnel efficiently prepared to perform their duties. The EOF's Emergency Manager (EM)
promptly contacted the TSC's SED to obtain an initial briefing and, based on a review of the site-specific EALs, to suggest that the SED consider reclassifying the event as a GE.
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The EM then assembled functional group leaders within an EOF conference room for the first of a series of concise " table head" briefings. Upon receiving assurances that the EOF was fully staffed and that all personnel were ready to perform their duties, the EM ended the first " table head" briefing by stating that he would call the SED in order to convey his readiness to assume overall command and control of the licensee's event response. The transfer of command and control was soon completed and announced within the EOF in an orderly and timely manner.
Subsequent " table head" briefings occurred at about a 30 minute frequency. Inputs from Illinois Department of Nuclear Safety (IDNS) and Illinois Emergency Management Agency liaisons, and a cadre of simulated NRC responders, were solicited by the EM during these briefings. The concise " table head" briefings were useful forums for sharing information on degraded plant conditions, related onsite priorities, and information of varying quality on offsite protective actions. The EM usually used the EOF's public address system to summarize highlights from the latest " table head" briefing.
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a Following the SED's GE declaration, the EM appropriately requested an interpretation of
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the associated, required PAR, which was incorrectly formulated by TSC staff and i
documented in their NARS message form number 4. Since the scenario postulated degraded power supplies, TSC staff were unable to send copies of NARS message
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forms to their EOF counterparts by facsimile machine. The EOF's copy of NARS
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message form number 4, which apparently was based on verbal communications
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between TSC and EOF communicators, included PAR information that did not match the j-procedurally incorrect PAR listed in the TSC staff's copy of NARS form number 4.
l The EOF Director, Radiation Protection Supervisor, EAUProtective Action Evaluator,
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and the EOF Emergency Advisor became involved in developing a consensus
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interpretation of the TSC staff's initial PAR, as documented in the EOF's copy of NARS l
form number 4. Several interpretations were voiced besides the procedurally correct
PAR. For example, they discussed whether " shelter" was being recommended in downwind sectors between 5 and 10 miles from the site, or if the " shelter"
i recommendation apolied to unevacuated areas within 5 miles of the site. Meanwhile, a
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plotter posted one of these interpretations and the protective actions chosen for implementation by offsite officials on the relevant status board.
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Offsite agencies' plans and procedures included dividing the EPZ into eight subareas I'
based on geopolitical boundaries. In response to the TSC staff's initial PAR, offsite
officials chose to evacuate Subarea No.1, which consisted of the area within about a j
five-mile radius of the site, to request that farmers within this subarea place milk
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producing animals on stored feed, and to advise the public in Subareas No. 6,7, and 8 j
to seek " shelter." Subareas No. 6,7, and 8 encompassed downwind sectors roughly 5 to i
10 miles from the site.
Four role players, who simulated being senior members of an NRC incident response Site Team, entered the EOF and were promptly invited by the EM to participate in the next " table head" briefing. The simulated NRC responders expressed concern about the EOF staff's ongoing multiple interpretations of the TSC staff's initial PAR.
The EM agreed with the senior NRC role player that the procedurally correct PAR was to shelter people within all portions of the EPZ that were not being evacuated. The EM soon accepted the EOF Director's prudent recommendation that NARS form number 5
- be generated to correct the PAR that was communicated by TSC staff to offsite officials by NARS message form 4. The NARS form number 5 also included a change to the status of a radiological release from " potential" to " occurring." However, an unclear and potentially misleading footnote was added to NARS message form number 5 indicating that the occurring radiological release was " calculated and not measured."
The PAR flow chart in' Attachment i to Revision 10 of EPIP RA-02," Protective Action Recommendations," and Step 9 of Attachment 5 to Revisio.,10 of EPIP EC-07,
" Emergency PiarQ tification" together contained adequately detailed guidance that persons in r" eeated portions of the plume exposure pathway Emergency Planning Zone - 'Z) between 2 and 10 miles from the site were to be advised to seek
" shelter," which meant that they were to go indoors and listen to an Emergency Alert
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System (EAS) station for further information. However, NARS form number 4 generated t
by TSC staff incorrectly indicated that the " shelter" portion of the PAR only encompassed all unevacuated areas within 2 to 5 miles of the site, while NARS form number 4
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i interpreted by EOF staff did not indicate what areas within 2 to'5 miles from the site were
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PAR-related guidance when making the initial and revised offsite PARS was considered -
l an Exercise Weakness.
' At about 11:20 a.m., a field team reported a 20 millirem per hour (mrem /hr) radiation field within 1 mile downwind of the containment structure. Protective measures staff l
generated an offsite dose projection and closely monitored radio communications with
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the field teams. A 6-hour default release duration was assumed. The EM adequately responded to a call from a senior State official regarding measured and projected offsite doses before convening another " table head" briefing.
Upon leaming of the initial and several subsequent reports of abnormal environmental radiological conditions and an unconfirmei report that State personnel were considering j
a PAR revision that would include evacuation of portions of the EPZ out to 10 miles from the site, the EM was properly concemed about the potential need to reassess the adequacy of the current PAR. The EM requested that protective measures staff perform further offsite dose projections, including a " worst case" projection assuming a loss of I
containment integrity.
The protective measures staff was unable to completely respond to the EM's and the simulated NRC responders' requests for several dose projections in a timely manner for several reasons. There was considerable confusion regarding the location of an offsite radiation level reading reported by a field team. Due to an actual modem failure on the primary dose assessment computer, the staff could not use this desk top computer until a technician was summoned to the EOF for repairs. The modem was to be utilized to obain offsite radiation measurements from the IDNS' monitoring system, possibly clarifying offsite radiation levels. The timeliness of the protective measures staff efforts was also adversely impacted by their attempts to assess an inconsistency in reported radiation measurements within one mile and further downwind of the site and to assess other reported radiation measurements. The EM received the offsite dose projection j
- calculations about one hour after they wcre requested. A revised PAR was developed and communicated to State officials shortly before the exercise was terminated by the
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licensee's exercise controllers. This PAR was correct.
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. Although Revision 4 of EPIP RA-16. " Computerized Radiological Dose Assessment,"
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b.5 Scenario and Exercise Control
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The inspectors assessed how challenging the scenario was to the licensee and i
evaluated the licensee's control of the exercise. The scenario was challenging and exercised the majority of the licensee's ernergency response capabilities. Overall,
l exercise control was mixed.
The Site' Area Emergency declaration was based on the occurrence of a station
blackout. However, the loss of power to the TSC was almost completely simulated.
t Portable light sources were retrieved from cabinets but were not actuated because the rooms' lights rer#ned energized. The controllers disallowed use of the copier and
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facsimile machines, but computers remained operational.
Lead exercise controllers made an appropriate decision to delay TSC responders'
transmission of the NARS message form number 4 related to the GE declaration in order to adhere to the scenario's pre-negotiated time line, which was designed to allow State and county officials sufficient time to demonstrate their responsibilities associated with each emergency classification decision. However, this controller decision was not efficiently and effectively communicated to all EOF staff which included liaisons from two State agencies.
Rather than having someone announce to all EOF staff the controllers' decision to delay transmission of the GE NARS message form generated by TSC staff, exercise controllers in the EOF elected to inform the EM, communicators, and State agency liaisons directly or indirectly over a period of about 30 minutes. As a result, some EOF staff performed under the assumption that a GE was ongoing, while others performed as though the event was still classified as a Site Area Emergency. This led to confusion.
For example, several EOF staff expressed concem over TSC counterparts' apparent inability to transmit this NARS message within the regulatory time limit. Meanwhile, the three field teams were told that a GE had been declared, while State agency liaisons, whose crrival in the EOF was unrealistically early, communicated this major decision to their counterparts in Springfield, Illinois, b.6 Licensee Self-Criticues The inspectors attended the licensee's self-critiques in the SMCR, TSC, OSC, and EOF which occurred immediately after the exercise. _ Exercise controllers solicited verbal and written inputs from the participants in addition to providing the participants with the
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controllers' initial assessments of personnel performance. The inspectors concluded that these initial self-critiques were thorough and in close agreement with the majority of the inspectors' observations.
The SMCR evaluators critically assessed operator performance in the SMCR. During the 2-hour plus critique, the evaluators identified problems with EOP implementation and system knowledge. Several other deficiencies were also identified (See " Exit Meeting Summary" for corrective actions).
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Summarv of Conclusions
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Evaluation of the license's exercise perforrnance is as follows:
Overall licensee performance during the 1998 emergency preparedness exercise e
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was adequate and licensee emergency plan implementation activities met
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regulatory requirements. Two Exercise Weaknesses were identified
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Overall performance in the SMCR was adequate. During the rapidly moving scenario, control room shift personnel properly diagnosed reactor events at the
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Notification of Unusual Event, Alert, and Site Area Emergency classification levels. Notifications were promptly made to offsite officials.
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Deficiencies in EOP implementation were identified. Specifically, operations
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personnel failed to start the hydrogen-oxygen monitors until 40 minutes after
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entering EOP-6, " Primary Containment Control. In addition, operations
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personnel did not determine whether a valid entry condition into EOP-9,
" Radioactivity Release Control", existed. Problems with EOP implementation
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were considered significant since similar concems were also identified during an j
emergency preparedness drill performed in October 1998.
e An operator error in the SMCR resulted in the loss of the RCIC system, the only o
source of cooling water for the reactor at the time.
The TSC staff's performance was adequate. Plant event analysis. event o
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j classification, notifications, briefings, and communications with other facilities were competently performed by the staff.
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e The transfer of command authority from the SMCR decision maker to the TSC decision maker did not occur until 56 minutes after the Alert declaration. Delay of activation until field monitoring teams were in place was unnecessary, One Exercise Weakness was identified conceming the TSC staff's setting of o
priorities for OSC tasks. A " Priority 1" designation was used for approximately half of the OSC teams. At one point, the inspectors noted that 6 of 10 OSC tasks / teams were designated as " Priority 1". This resulted in inefficient use of resources on the most critically important tasks. Also, a sense cf urgency was not exhibited when repair teams were briefed and dispatched from the OSC.
One Exercise Weakness was identified concerning' PARS. The initial PAR o
transmitted to State representatives upon declaration of a GE did not advise that persons in the non-evacuated portions of the EPZ should go indoors and monitor EAS broadcasts, although this was the default PAR listed in the licensee's
- procedures. An unclear PAR revision was subsequently transmitted by EOF staff and was eventually corrected before the exercise was terminated.
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_ A backup power supply ceased powering the TSC PA system after 26 minutes of operation. The loss of the PA system meant that TSC managers' briefings were not audible in the OSC.' An available megaphone was not utilized.
Overall performance of OSC management and staff was mixed, with examples of o
both good and poor individual performance. Overall command and control of the
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facility was insufficient. The OSC management did not maintain good awareness of deployed teams' progress or results. The OSC Director seldom stayed in the
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command area of the OSC where teams' reports were being received so that these reports could promptly be assessed and an overall perspective of deployed teams' activities could be maintained.
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- The OSC team briefings followed the same guidelines for high priority tasks as for lower priority tasks. There were no apparent management expectations for briefing and dispatching higher priority teams from the OSC more expeditiously than lower priority teams.
l The EOF protective measures staff was unable to completely respond to the e
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EM's and simulated NRC responders' requests for several offsite dose projections in a timely manner.
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e A modem on the computer assigned to the EOF's protective measures staff actually failed and the staff was unaware that an available laptop computer also had an installed modem.
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e Self-critiques following termination of the exercise were critical and included inputs from controllers and exercise participants. In particular, the SMCR evaluators critically assessed operator performance.
P8 Miscellaneous EP issues P8.1 (Closed) Insoection Followuo item No. 50-461/98003-13: Ability to complete follow-up State notifications. During this exercise, follow-up State notifications were performed acceptably. This item is closed.
P.8.2 l (Open) Insoection Followuo item No. 50-461/98003-16: Activation and response of the autodialer system. Licensee personnel stated that interfacing the new autodialer system with the telephone system has been difficult, requiring vendor evaluation and a change
= to a different interface. This has delayed full autodialer system implementation. This item will remain operi.
P.8.3 _ (Closed) Insoection Followuo item No. 50-461/98003-18: Transfer of command and control from the SMCR decision maker to the TSC decision maker. During this exercise, transfer of command and control of emergency responsibilities from the SMCR's SM to the TSC's SED was very orderly. This item is closed.
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P.8.4 (Closed) Insoection Followuo item No. 50-461/98003-20: Sample control in the EOF.
Sample control in the EOF was determined to be adequate based on inspection and discussions with the licensee. This item is closed.
P.8.5 { Closed) Inspection Followuo item No. 50-461/98003-21. SMCR to TSC staff l
communications. During this exercise, SMCR to TSC staff communications were j
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generally good. This item is closed.
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l P.8.6 (Closed) Insoection Foilowuo item No. 50-461/98003-22 Ability to disseminate l
information to plant personnel. During this exercise, adequate information was provided l
to plant personnel via the plant PA system. This item is closed.
P.8.7 (Closed) inspection Followuo item No. 50-461/98009-04: Procedural definition of how the SED will control inplant teams. Site procedures define how the SED is to control inplant teams, including how operators will report to the OSC once that facility is activated. This item is closed.
V, Manaaement Meetinas X.1 Exit Meetina Summary The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection on November 20,1998. The inspection team leader stated that, although the licensee's overall exercise performance was adequate, several performance issues
were identified. The licensee acknowledged the preliminary findings presented. The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identified.
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I The licensee stated that the issues discussed would be further evaluated and that corrective actions were planned. The license's enclosed letter, dated December 4,1998, summarized the licensee's planned corrective actions resulting from this exercise.
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PARTIAL LIST OF PERSONS CONTACTED L
Licensee
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l-W. MacFarland IV - Chief Nuclear Officer G. Hunger, Manager - Clinton Power Station M. Wyatt, Manager - Recovery W. Romberg, Manager - Nuclear Station Engineering Department R. Phares, Manager - Nuclear Safety and Performance improvement G. Baker, Manager - Quality Assurance J. Goldman, Manager - Work Management V. Cwietniewicz, Manager - Maintenance
. J. Gruber, Director - Corrective Action W. Maguire, Director - Operations j
- J. Sipek, Director - Licensing
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. D. Smith, Director, Security and Emergency Planning W. Yaroz, Emergency Planning K. Evans, Emergency Planning
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1J. Place, Director - Plant Radiation and Chemistry j
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J. Barron, Director - Plant Engineering NRC
' T. Pruett, Senior Resident inspector K. Stoedter, Resident inspector C. Brown, Resident inspector lilinois Department of Nuclear Safety D. Zemel, Resident Engineer INSPECTION PROCEDURES USED IP 82301 Evaluation of Exercises for Power Reactors IP 82302 Review of Exercise Objectives and Scenarios for Power Reactors l
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ITEMS OPENED, CLOSED, AND DISCUSSED Ooened 50-461/98027-01 IFl The transfer of command authority to the TSC's senior responder was slow due to a flawed procedure.
50-461/98027-02.
IFl Exercise Weakness involving PAR formulation and transmission by TSC and EOF staffs.
50-461/98027-03 IFl Exercise Weakness involving TSC staff not appropriate {y setting priorities of inplant teams and a lack of a sense of urgency in briefing and dispatching teams.
50-461/98027-04 IFl UPS failure in the TSC causes lack of PA system capab3ity in TSC i
and adjacent OSC.
Closed
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i 50-461/98003-13 IFl Ability to complete follow-up state notifications.
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50-461/98003-18 IFl Transfer of command and control from the SMCR decision maker to the TSC decision maker.
50-461/98003-20 IFl Sample controlin the EOF.
50-461/98003-21 IFl SMCR to TSC staff communications.
50-461/98003-22 IFl Ability to disseminate information to plant personnel.
50-461/98009-04 IFl Procedural definition of how the SED would control inplant teams.
Discussed 50-461/98003-16 IFl Activation and response of the autodialer system.
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LIST OF ACRONYMS'USED
CFR Code of Federal Regulaticns
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CRS-Control Room Supervisor 4'
- DRP'
Division of Reactor Projects DRSl Division of Reautor Safety j
<EALL Emergency Action Level
~EAS Emergency Alert System.
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_ Emergency Manager EOF
- Emergency Operations Facility
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EOP-Emergency Operating Procedure -
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EPIP Emergency Plan Implementing Procedure
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"EPZ
- Emergency Planning Zone
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Emergency Response Data System ERO'
Emergency Response Organization FEMA Federal Emergency Management Agency GE.
General Emergency HPCI High Pressure Coolant injection
IDNS lilinois Department of Nuclear Safety I
'IFl inspection Follow up Item IP inspection Procedure 1JPIC Joint Public Information Center NARS
- Nuclear Accident Reporting System NPF:
Nuclear Power Facility;
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Nuclear Regulatory Commission
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iNRR Office of Nuclear Reactor Regulation OSC Operations Support Center
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~ Public Address -
PAR Protective Action Recommendation PDRl
. NRC Public Document Room PMDL Protective Measures Director -
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Reserve Auxiliary Transformer -
RCIC.
' Reactor Core Isolation Cooling RPV1 Reactor Pressure Vessel iSED.
. Station Emergency Director SM
- Shift Manager _
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iSMCR.
Simulator Main Control Room
< - TSC
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- Uninterruptible Power System
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Clinton Power Station
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P O Box 678 g
Clinton. IL 61727 l
Tel 217 935 5623 i
Fax 217 935-4632 Walter G. MacFarland IV I
Senior Vee President and Chsef Nuclear Officer POWER pgg26 An Illinova Company December 4,1998,.,
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Docket No. 50-461 Mr. James Regional Administrator,RegionIII
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U.S. Nuclear Regulatory Commission 801 Warrenville Road Lisle, Illinois 60532-4351 Subject: Corrective Actions for the 1998 Clinton Power Station Emergency Response Organization Integrated Graded Exercise
Dear Mr. Caldwell:
The Clinton Power Station (CPS) Graded Exercise was conducted on November 18,1998. The results of this exercise demonstrated that the CPS Emergency Response Organization (ERO) could protect the health and safety of the public. However, several areas for improvement were identified during the critique process. The more significant critique findings are identified below.
Improper Protective Action Recommendations (PARS) were provided to the state
by the TSC and EOF. This was originally caused by personnel in the Technical Support Center (TSC) marking a Nuclear Accident Reporting System (NARS)
notification form incorrectly. This error was subsequently detected by personnel in the EOF; however, it took approximately 20 minutes to correct the improper notification. A second improper PAR was caused by incorrectly reporting field team readings. Field readings taken at the protected area fence were reported to dose assessment personnel as readings from the site boundary. The protected area fence is substantially closer to the site than the site boundary. This error confused dose assessment personnel as Geld readings were higher than expected and resulted in an error when reporting PARS.
The prioritization of repair activities by the Operations Support Center (OSC) and
TSC was ambiguous and inadequate. Both of these facilities identified multiple activities as being priority 1; however, a sense of urgency was not exhibited when dispatching the repair teams associated with these activities. Additionally, the practice ofidentifying multiple priority 1 activities can create an inefficient use of resources and a lack of focus on critical emergency response activities.
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U.603126 Page 2
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Turnover of command authority from the Main Control Room (MCR) to the Technical e
Support Center (TSC) was hindered due to the need for field team members to staff the EOF as required by EPIP EC-01, " CPS Emergency Response Organization and Staffing." These teams were available within the required time, but the TSC was unaware of their availability.
The Operational Support Center (OSC) Supervisor became involved in specific tasks
and did not maintain proper oversight of OSC activities at all times.
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In addition to the findings identi6ed above, operating errors were made by the crew in
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the simulator.
Illinois Power (IP) is in the process of taking action to improve performance in the areas described above. The following is a list ofcorrective actions to address these areas:
A review of the PAR process is being performed to streamline the process by reducing
the number of people involved in PAR decision making Additionally, the PAR flowchart is being revised to describe the default PAR recommendations in laymen's terms and to make the recommendation easily transferable to the NARS noti 6 cation form. Remedial training will also be provided to individuals involved in the PAR process. Field team members, field team coordinators and dose assessment personnel are being provided remedial training on the difference between the site boundary and the protected area fence. Pre-established Seid monitoring points for the site boundary are also being established and additional tre!.i.g will be provided to field team members to ensure the proper areas for taking field readings are understood and reported properly. Remedial training will also be provided to the TSC and EOF communicators on properly completing the NARS forms and to reaffirm the requirement for notifications and follow-up noti 6 cations to state and federal agencies.
Appropriate procedure (s) will be revised to provide guidelines on establishing
priorities during emergency events and p~liting dispatch of high priority OSC repair teams. Training will be provided to appropriate personnel on the new procedures.
EPIP EC-01, will be revised to eliminate the requirement for two field teanas to be
staffed in the EOF prior to activating the TSC.
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Remedial training will be provided to OSC Supervisors on maintaining oversight of e
activities in the OSC.
The errors made by the operating crew in the simulator are being addressed separately
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by the Operations Continuing Training Program.
To demonstrate the effectiveness of the corrective actions being taken, an EOF / Joint e
Public Information Center (JPIC) facility drill, a TSC/OSC/ Simulator facility drill, and
. an integrated drill have been scheduled before the end of the first quarter of 1999.
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Although the results of the graded exercise on November 18,1998, detaonstrated that the Clinton Power Station ERO can adequately protect the health and safety of the public, prompt corrective actions are being taken to address the performance weaknesses noted during the exercise.
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Ifyou have any questions or require additional information, please contact Mr.
Dennis L. Smith, Director-Security and Emergency Preparedness, at (217) 935-8881, extension 3356.
Sincerely yours,
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Walter G. MacFarland, IV Senior Vice President and ChiefNuclear Officer JRF/krk cc:
J. Creed, Branch Chief, Division ofReactor Safety NRC Resident Office, V-960 Document ControlDesk
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