IR 05000482/1993020
| ML20059A120 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 12/21/1993 |
| From: | Murray B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20059A118 | List: |
| References | |
| 50-482-93-20, NUDOCS 9312300021 | |
| Download: ML20059A120 (16) | |
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t APPENDIX U.S. NUCLEAR REGULATORY COMMISSION
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REGION IV
Inspection Report:
50-482/93-20
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Operating Licensed: NPF-42 Licensee: Wolf Creek Nuclear Operating Corporation
P.O. Box 411
Burlington, Kansas 66839 Facility Name: Wolf Creek Generating Station Inspection At:
Burlington, Kansas Inspection Conducted:
November 29 through December 3, 1993 Inspectors:
Wesley L. Holley, Senior Radiation Specialist (Team Leader)
j D. Blair Spitzberg, Ph.D., Emergency Preparedness Analyst J. Fredrick Ringwald, Resident Inspector
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Accompanying
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Personnel:
John Bumgardner, Battelle Pacific Northwest Laboratories Jim Nickolaus, Battelle Pacific Northwest Laboratories
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Approved:
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BraiWe Murray,T Chief, f4cilities Date Inspection Progr Section
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Inspection Summary
Areas Inspected:
Routine, announced inspection of the licensee's performance i
and capabilities during an annual exercise of the emergency plan and implementing procedures.
The team observed activities in the Control Room,
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Technical Support Center, Operational Support Center, and the Emergency Operations Facility.
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i Results:
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The misclassification of the ALERT and other recommended
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misclassifications were identified as an exercise weakness (Section 2.1).
Communication problems in the control room were
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identified as a portion of a communications and information flow exercise weakness that was observed in other facilities-(Section 2.1).
The Technical Support Center was staffed and activated promptly, and the
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response staff appeared to understand their duties and responsibilities.
9312300021 931222
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PDR ADDCK 05000482 G
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--2-l The Technical Support Center contributed to an exercise weakness that was identified concerning communication and information flow which also occurred'in other_ facilities (Section 3.1).
Communications and information flow in the Operational Support Center '
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were also identified as a portion of the exercise weakness in this area.
The lack of Operation Support Center personnel proficiency in locating
. items in the warehouse to mitigate the emergency was identified as an exercise weakness.
Radiation protection practices by Operational
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Support Center personnel were identified as an exercise weakness
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(Section 4.1).
The Emergency Operations Facility was staffed and activated promptly.
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Command and control were effective, and actions by dose' assessment personnel were observed to be a strength. 'An exercise weakness was identified concerning radiological assessment problems which resulted.in the issuance of information to offsite authorities which. contained
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significant inconsistencies relative to recommended protective actions (Section 5.1).
An exercise weakness was identified in the. areas of exercise preparation
and control (Section 6.1).
The licensee's critique was good and properly identified weak areas in
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need of corrective action.
In addition to-the general weakness categories identified by the NRC team, the licensee's critique identified an additional exercise weakness that was not found by the inspectors. The licensee's grouping of weak. areas was different from that of the inspection team, but was. adequate (Section 7.1).
Summar_y of Inspection Findings:
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Exercise Weakness 482/9320-01 was opened (Section 2.1).
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Exercise Weakness 482/9320-02 was opened (Sections 2.1, 3.1, 4.1,
and 5.1).
Exercise Weakness 482/9320-03 was opened (Section 4.1).
- Exercise Weakness 482/9320-04 was opened (Section 4.1).
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Exercise Weakness 482/9320-05 was opened (Section 5.1).
- Exercise Weakness 482/9320-06 was opened (Section 6.1).
Attachment:
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Attachment - Persons Contacted and Exit Meeting
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-3-DETAILS
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1 PROGRAM AREAS INSPECTED (82301)
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The licensee's annual emergency preparedness exercise began at 8 a.m. on December 1, 1993. The exercise was a comprehensive offsite participation-t exercise and was evaluated by the Federal Emergency Management Agency. The NRC did not participate in the exercise.
Initial conditions-for the exercise included the plant having been operating at 100 percent power for the past 14 days and was on the sixth cycle of a middle of life core. The Wolf Creek Generating Station electrical power system was in a very high demand situation.
Major events in the scenario included a fire in the switchgear room No. I resulting in the 4160 volt bus NB01 experiencing damage and becoming deenergized. Subsequently, diesel generator "A" started, but it was unable to reenergize the damaged bus.
A 1000 gpm Loss of Coolant Accident occurred at normal operating pressures, but its location was unidentified. The reactor
tripped and safety injection was initiated. The size of the Loss of Coolant-Accident increased and exceeded the makeup capacity. _ Reactor vessel level
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soon decreased to below the top of the core.
A monitored, filtered release path to the environment occurred when a hydrogen burn breached a containment
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exhaust penetration.
The inspection team identified various concerns during the course of the exercise; however, none were of the significance of _ a deficiency as defined in.
Each observed concern can be characterized as an exercise weakness or as an area recommended for improvement. ' An exercise
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weakness is a finding that a licensee's demonstrated level of preparedness
could have precluded effective implementation of the emergency plan in the event of an actual emergency.
It is a finding that needs licensee's corrective action. Other observations were documented which did not have a
significant negative impact on overall performance during the exercise but still could be evaluated and corrected as determined appropriate by the licensee.
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2 CONTROL ROOM (82301-03.02.b.1)
The inspection team observed and evaluated the Control Room staff as they performed tasks in response to the exercise. These tasks included detection and classification of events, analysis of plant conditions, implementation of
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corrective measures, notifications of offsite authorities, and adherence to the emergency plan and implementing procedures.
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2.1 Discussion The Control Room simulator was used to initiate the exercise, and dynamic simulation of the exercise was accomplished until the simulator aborted the scenario at 10:39 a.m.
The simulator was reactivated and returned to the
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scenario time-line previous to the abort time. Subsequently, the simulator i
aborted the scenario on three more occasions at the same point in the i
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scenario. Because of this, dynamic simulation of the scenario was terminated, and the controllers directed the remaining portion of the exercise.
During the exercise, the Shift Supervisor had difficulty with event l
classification and recognition of initiating conditions as follows:
At 8:25 a.m., the Shift Supervisor inappropriately classified the fire
in the NB01 switchgear event as an ALERT under " Fire Challenging a a
Fission Product Barrier." The Shift Supervisor believed that loss of
the safety injection pumps constituted a challenge to the fuel clad.
This interpretation was outside the criteria of Procedure EP 01-2.1,
" Emergency Classification," Attachment 2, " Indications of Fuel Cladding Breach or Challenge." The correct classification for the conditions which existed at 8:25 a.m. was an Unusual Event.
At approximately 9:05 a.m., the Shift Supervisor recommended to the
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Technical Support Center to escalate the emergency classification to a Site Area Emergency based on offsite dose projections which were run at 8:42 a.m.
These dose projections assumed that there was a release path to the environment and a source term based on a design basis loss of coolant.
The actual plant conditions at the time this recommendation was made were a loss of coolant that was much smaller than a design basis accident loss of coolant, and no release path established or anticipated. The Technical Support Center appropriately disagreed with
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the recommendation to escalate.
At 9:20 a.m.,
the Shift Supervisor again recommended to the-Technical
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Support Center to escalate the emergency classification to a Site Area Emergency based on a loss of coolant accident in progress with both
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safety injection pumps out of service. The Shift Supervisor considered l
these conditions to be a challenge to the fuel clad fission product barrier and a defeat of the Reactor _ Coolant System fission product barrier.
This interpretation of fuel clad challenge did not meet the
criteria of Procedure EP 01-2.1 " Emergency Classification,"
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Attachment 2, " Indications of Fuel Cladding Breach or Challenge." The actual plant conditions at the time the recommendation was made were a i
1000 gpm Loss of Coolant Accident which was being compensated for by the
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B Centrifugal Charging Pump.
The core was covered with no clad damage,
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and no release from the containment was_in progress. The Technical Support Center appropriately disagreed with the Shift Supervisor's recommendations.
The inappropriate ALERT classification and the_ subsequent errors in-recognition of initiating conditions were identified as an exercise weakness (482/9320-01).
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Communications and information flow were weak during the exercise in the Control Room as noted by the following examples:
The players in the Control Room often did not know who was in charge.
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The Shift Supervisor did not announce who was the Duty Emergency
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-5-Director or announce the Duty Emergency Direct 2r/ Duty Emergency Manager transfer of responsibility to the personnel in the control room.
At 9:05 a.m., the Shift Clerk was asked'by a controller if the Technical
Support Center had assumed control. The_ shift clerk did not know the
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answer to the controller's question.
The actual transfer of responsibility to the Duty Emergency Director in the Technical Support'
Center took place at 8:51 a.m.
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The Lead Control Room Controller was under the impression that the
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Technical Support Center had the Duty Emergency Director responsibility, but he only knew this because the Lead Control Room Evaluator told him.
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i No general briefings were given by the Shift Supervisor in the Control e
Room.
At' approximately 9:45 a.m., the Operations Administrative Coordinator
and a Reactor Operator noted that reactor vessel water level started-dropping and the core exit temperatures were rapidly rising. The
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Control Room Supervisor and Shift Supervisor were not promptly informed-of this serious situation.
The announcement of Site Area Emergency over the Gaitronics was delayed
11 minutes from the declaration of the Site Area Emergency as a result of a the third Reactor Operator completing another task before making the announcement and not being able to find the specific message required for the drill announcement of Site Area Emergency. This resulted in delayed start of the assembly and accountability.
At 8:30 a.m., erroneous meteorological information was issued to offsite
authorities with the initial notification of the ALERT. The erroneous information reported the wind direction as 12 degrees. Actual wind direction at the time was 44 degrees.
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Following the-declaration of the General Emergency at 10:37 a.m., there
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were no plant public address, announcements made to inform onsite personnel of the General Emergency as specified in Procedure EPP 01-1.0,
" Control Room Organization," Attachment 4.0.
These communication and information flow problems were identified as'part of communication and information flow exercise weakness (482/9320-02). Other information flow problems are also discussed in Sections 3.1,- 4.1, and 5.1.
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2.2 Conclusion
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The misclassification of the ALERT and other errors in recognition of
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initiating conditions were identified as an exercise weakness.
Communication problems in the control room were identified as a portion of a Communications
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and Information Flow exercise weakness that was observed in other facilities.
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-6-3 TECHNICAL SUPPORT CENTER (32301-03.02.b.2)
The inspectors observed the operation of the Technical. Support Center from activation through termination of the exercise.
The inspectors evalucted
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staffing, command and control, technical assessment, formulation of protective
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action recommendations, and adherence to the emergency. plan and implementing-
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procedures.-
3.1 Discussion The Technical Support Center was staffed and activated promptly at 8:51 a.m.
Response staff appeared to be trained and understood their duties and responsibilities.
Habitability surveys were performed by the radiation protection technicians, and the accountability of Technical Support Center personnel was tracked by the security organization and initially completed at 8:55 a.m.
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The Technical Support Center engineering team support was good with one
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exception. The Operations Engineering Coordinator requested clarification
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from the engineering team concerning use of hydrogen recombiners under
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100 percent humidity conditions versus dry conditions at 4 percent hydrogen concentrations.
The engineering team researched the question but was
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distracted prior to providing the Operations Engineering Coordinator a
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response. This is considered an improvement item.
The Technical Support Center experienced communication and information flow
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problems as noted by the following examples:
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The Duty Emergency Director briefed the Technical Support Center e
frequently, but certain important'information was not always passed to the Technical Support Center personnel.
For example at 10:36 a.m., the
Duty Emergency Director knew about the simulator problem and that the Vital Bus NB02 was lost but did not inform Technical Support Center staff until the 10:57 a.m. briefing.
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updated at 12:27 p.m. to " Release in Progress." This information was not communicated to all Technical Support Center personnel until the
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briefing at 1:19 p.m.
The Radiological Status Board was updated to " Release Terminated" at
2:25 p.m., but this was not communicated to the entire Technical Support
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Center staff until the 2:48 p.m. briefing.
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Communication and information flow problems in the Technical Support Center'
I were identified as part of the communication and information flow exercise weakness (482/9320-02). Other communication and information flow problems are
also discussed in Sections 2.1, 4.1, and 5.1.
There were several observations made by the inspectors in the Technical Support Center that contributed to the exercise weakness (482/9320-06) in the
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3.2 Conclusion The Technical Support Center was staffed and activated promptly, and the response staff appeared to understand their duties and responsibilities. The Technical Support Center contributed to an exercise weakness concerning communication and information flow which also occurred in other facilities.
4 OPERATIONAL SUPPORT CENTER (82301-03.02.b.4)
The inspection team evaluated the performance of the Operational Support Center staff as they performed tasks in response to the exercise to determine whether the Operational Support Center would be effective in providing emergency support to operations.
4.1 Discussion The Operational Support Center was well organized, and recordkeeping appeared to be complete. The Operational Support Center was staffed and functioning 18 minutes after the declaration of the ALERT.
There were some minor difficulties in activating the Operational Support Center.
Even though the phone jacks and cords were color coded, the Operational Support Center Clerk was initially confused over the connection of the Operational Support Center telephones since the same label material identified the telephone number on the jack and the phone function on the telephone set.
There was a 17 minute delay in getting the two Operational Support Center clocks synchronized. The layout of the Operational Support Center was awkward. There was no common area for workers to wait and prepare for assignments, and many workers sat on the floor in hallways and on stairs.
This required the Operational Support Center Supervisor to give each team briefing once for the Onsite Survey Team Director and Operational Support Center Clerk, again for the Radiological Protection Technicians and any worker in the hallway near the Emergency Plan Cabinets, and a third time for workers near the Operational Support Center Accountability Clerk. Despite this difficulty, the Operational Support Center Supervisor gave frequent and thorough briefings to those Operational Support Center staff members who were present in the Operational Support Center.
Since Operational Support _ Center members used multiple doors to enter and exit the Operational Support Center, accountability was not a simple task; however, no accountability discrepancies were noted. The preceding problems are
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considered improvement items.
The dispatch of the initial team was delayed approximately 15 minutes due to several coordination problems. The electricians were told to expect to be dispatched at 8:48 a.m., but when they asked the Operational Support Center Supervisor if they should don protective clothing,.they were told to wait.
They were directed to t ?n protective clothing at 8:55 a.m., but the assigned radiation protection technician did not get the same instructions, and this was not recognized during the team briefing at 9:08 a.m. when the two electricians dressed in yellow protective clothing stood next to the radiation protection technician dressed in street clothes. This was finally recognized
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At 9:25 a.m., the three team members attempted to obtain respirators when an Operational Support Center radiation protection technician determined that the radiation protection technician and one electrician did not have current respirator fit tests. The controller initially said that the respirator fit tests could be simulated, but then decided to consult with the lead controller. The lead controller said that this could not be simulated and directed the Operational Support Center staff to decide what to do given this actual situation. The Onsite Survey Team Director discussed this with the Radiological Assessment Coordinator, and tl.ey determined that since no release was in progress, and none was anticipated, the team could be dispatched without respirator qualification. Team No. I was dispatched to the-field at 9:28 am.
The subsequent teams were dispatched with more efficiency and better coordination than the first team. The Emergency Team Briefing Checklists for teams Nos. 4, 5, and 6 were not signed by the Onsite Survey Team Director.
The preceding problems are identified as improvement items.
The Operational Support Center's function appeared to be limited to forming and dispatching teams. Once teams left the Operational Support Center, they did not communicate with or get any additional support from the Operational-Support Center until they returned from the field.
In addition, this scenario was not particularly challenging to the Operational Support Center staff.,
only six teams were dispatched during the scenario, and one of these teams was simulated.
For approximately 90 minutes during the exercise, the Operational Support Center staff had very little to do. At noon, several teams were d;rected to return to the Operational Support Center so team members could eat lunch, but at the same time simulate that they were remaining and continuing with the work. After these teams ate lunch, they did not return to the field and the simulation of their presence in the field continued. This is also q
identified as an improvement item.
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Several communication problems were identified. The Operatienal Support Center was never notified of the General Emergency declaration and learned of
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Support Center and team No. 3.
Communication problems were identified regarding teams activities.
For example, during its team briefing, team No. I was initially assigned an expected duration in the field of 40 minutes.
However, the team remained in the field for more than 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />, yet the initial stay time was never revisited by the Operation Support Center, Technical
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Support Center, nor the team. Another communications problem was noted when team No. I contacted the control room at 10:08 a.m. using the Gai-Tronics and asked for permission to return to NB01 switchgear room. This communication should have been with the Technical Support Center.
These communication problems are considered to be part of communications and information flow exercise weakness (482/9320-02). Communication and information flow problems are also discussed in Sections 2.1, 3.1, and 5.1.
Team No. 3 was dispatched to obtain temporary power cables and lugs from the warehouse and take them to team No. I where the two teams =would use them to i
provide emergency power to residual heat removal pump A.
When Team No. 3
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arrived at the warehouse at 10:39 a.m., they found the warehouse locked. At 10:45 a.m. security arrived, and at 10:49 a.m, team No. 3 arrived at the issue window area.
Forty six minutes later, after receiving assistance from the
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. warehouse supervisor, team No. 3 finally located the cables and lugs. This delay occurred because the team No. 3 members were not familiar with how to i
translate the warehouse locations provided by the procurement computer program to physical warehouse locations. This delayed the recovery of. reactor coolant
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injection capability by 52 minutes and exacerbated the consequences of the
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emergency. This problem in Operational Support Center staff. proficiency was identified as an exercise weakness (482/9320-03).
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The Operational Support Center status board showed the priority of team No. I to be "high."
The mission of team No. 3 was to obtain materials to assist i
team No.1 in completing its mission; however, the Operational Support Center
status board only showed the priority of team No. 3 to only be " medium." This inconsistency did not result in any conflicting actions but may have been potentially confusing.
Several poor radiological practices were observed from the Operational Support
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Center as follows:
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The Radiological Protection Technician with team No. 6 dropped a
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tele-detector survey meter as the team was departing the Operational Support Center.
However, the Radiological Protection Technician did r.ot
response test the meter to determine if the drop damaged the meter nor'
did he return to the Operational Support Center to get the other-l instrument. The meter which was dropped was used by the Radiological Protection Technician in fields with simulated dose rates of 10-130 R/h.
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The Radiological Protection Technician with Team No. I walked through
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the door between NB02 and NB01 without looking at the survey meter until he was at least 15 feet into NB01.
The Radiological Protection Technician with Team No. 6 walked through
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door 15012 without looking at the Tele-Detector until he was at least i
15 feet into the room.
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The Radiological Protection Technician with team No. 6 wore his
i 0-500 mrem pocket ion chamber dosimeter inside his protective clothing and could, therefore, not look at its reading frequently as required by Step 6.2.8 of Procedure ADM 03-002, " Radiation Worker Guidelines,"
Revision 11.
l The Radiological Protection Technician with team No. 6 conducted stay I
time mental calculations and discussed whether mechanics would be
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willing to volunteer for emergency 25 Rem exposure while standing in a 5 Rem per hour field rather than returning to a 130 mrem per hour field
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about 30 feet away.
This discussion took approximately 3-4 minutes and
resulted in approximately 330 mrem of unnecessary dose per person.
j As discussed above, team No. I was dispatched with one electrician and
the Radiological Protection Technician without current respirator fit tests. The decision to dispatch them included the decision to bring them back to the Operational Support Center if conditions changed to
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require them to be' in respiratory protection. When the Radiological Emergency Coordinator decided to place all onsite repair teams in self-contained breathing apparatuses, these workers were not recalled to the Operational Support Center, and they remained in the field until after the release was well in progress.
j The Operational Support Center Supervisor did not post the "No Eating,
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Drinking, Smoking, Chewing" sign until habitability was verified as
required by Step 4.2.1.6 of Procedure EPP 01-4.2, " Operations Support Center Activation / Operation," Revision 9, nor was this communicated to the Operational Support Center staff during initial Operational Support
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Center staff briefings.
These above examples of poor radiological protection practices were identified-i as exercise weakness (482/9320-04).
4.3 Conclusions Communications and information flow in the Operational Support Center were also identified as a portion of the exercise weakness in this area. The lack of Operational Support Center personnel proficiency in locating items in the
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warehouse to mitigate the emergency was identified as an exercise weakness.
Poor radiation protection practices by Operation Support Center personnel were t
identified as an exercise weakness.
5 EMERGENCY OPERATIONS FACILITY (82301-03.02.b.3)
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The inspectors observed and evaluated the Emergency Operations Facility staff'
as they performed tasks in response to the exercise.
These tasks included activation of the Emergency Operations Facility, accident assessment-and classification; offsite dose assessment; notifications; protective action
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decisionmaking; and interaction with State, local officials, and offsite field
monitoring teams.
5.1 Discussion The Emergency Operations Facility was staffed promptly and was activated about
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40 minutes after the declaration of the Site Area Emergency.
Emergency
Operations Facility staff appeared to be trained and proficient in carrying
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out their response duties. Overall command and control in the Emergency
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Operations Facility was good. The Duty Emergency Manager held periodic
managers meetings to discuss status and priorities. The coordination of
activities between licensee and state representatives located in the Emergency-Operations Facility was effective.
The General Emergency was properly classified from the Emergency Operations Facility based upon radiation levels
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in containment.
Notification messages were issued in a timely manner after
the assumption of these respcnsibilities from the Technical Support: Center.
Following the declaration of the General Emergency at 10:37 a.m., there were no plant public address announcements made to inform onsite personnel of the
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General Emergency as specified in Procedure EPP 01-1.0, " Control Room i
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Organization," Attachment 4.0.
The failure to announce the declaration of a General Emergency was identified in Sections 2.1, 3.1, and 4.1 as part of the communications and information flow exercise weakness (482/9320-02).. Other i
communication and information flow problems are also discussed in Sections 2.1, 3.1, and 4.1.
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Dose assessment personnel in the Emergency Operations Facility were very alert to changing plant status and were anticipatory of changing conditions.
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example, the Dose Assessment Supervisor was the first individual in the Emergency Operations Facility to question the discrepancy between the report that both engineered safety feature electrical busses had been lost, and the fact that one containment high-range radiation monitor, which is powered by the engineered safety feature buses, was still in service. Another example was noted when the Dose Assessment Supervisor was questioning slope changes in
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trended data for containment hydrogen level and containment pressure during the time that the scenario simulation was failing. This was anticipatory of a potential hydrogen burn which would have altered dose projection assumptions.
At one point in the exercise, offsite radiological assessments performed in the Emergency Operations Facility resulted in information being issued to offsite authorities which contained significant inconsistencies.
Starting about 9:45 am, the loss of coolant began increasing in size such that core uncovery and fuel cladding damage occurred. This led to radiation levels in
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containment measuring over 100,000 R/h. At 12:15 p.m., the scenario called for a hydrogen burn in containment which breached the containment building mini-purge exhaust penetration. At that time, a radiological release to the
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environment began.
The source term was scrubbed by some containment spray flow and was passed through the auxiliary building ventilation system filter train before being monitored through the unit vent. Thus, according to the
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scenario data, the radiological assessors were being presented with radiological information indicating a release consisting almost entirely of noble gases.
Dose projections computed in the Emergency Operations Facility after the initiation of the release generated very large child thyroid dose rate and integrated doses offsite.
Several dose projections were generated based on
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different assumptions, all yielding similarly high child thyroid dose rates.
Dose projections assumed a largely unfiltered release with high iodine
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concentrations.
In some projections, design basis iodine to noble gas ratios were used.
In others, the iodine to noble gas ratio was based on a postaccident containment atmosphere analysis. The iodine release rate
assumptions were conservative considering the filtered release pathway and led i
to offsite dose projections which were not anticipated for this scenario.
In the absence of reliable iodine release rate -information, actual field measurements of iodine concentrations were not initiated by licensee field teams until 54 minutes after the start of the release.
Despite having field teams positioned downwind before the release began, as of 1:45 p.m. no field team sample results had been reported to quantify iodine concentrations. At 1:45 p.m.,
1.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> after initiation of the release, exercise controllers injected field team iodine concentration data to players in order to restore
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At 1:07 pm, the Emergency Operations facility issued Followup Notification Message E0F-006. This message communicated to offsite authorities the very large dose projections which had been generated based on the: uncertain assumptions of the iodine release component.
For example, this message showed the projected child thyroid dose rate at 10-miles. distance downwind to be 81 rem /h with a projected integrated child thyroid dose of 160 rem. Actual dose rates of this magnitude would necessitate protective actions beyond the L
10-mile distance for which the licensee had recommended evacuation. Although the licensee had discussed protective action recommendations beyond the 10-mile emergency planning zone, no such recommendations were made with dose projection information issued in Message E0F-006.
The offsite radiological assessments which resulted -in information being communicated to offsite authorities which contained significant inconsistencies relative to recommended protective actions was identified as an exercise weakness (482/9320-05).
5.2 Conclusions The Emergency Operations Facility was staffed and activated promptly. Command and control were effective, and actions by dose assessment personnel were observed to be a strength. An exercise weakness was identified for radiological assessment problems which resulted in the issuance of information to offsite authorities which contained significant inconsistencies relative to recommended protective actions 6 SCENARIO AND EXERCISE CONDUCT (82301)
The inspection team made observations during the exercise to assess the
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challenge and realism of the scenario and to evaluate the conduct of the exercise.
6.1 Discussion Exercise preparation and control was weak, resulting in difficulty in conducting the exercise, and in reducing its training benefit. This was observed in areas relating to the scenario, exercise control, and simulation.
6.1.1 Scenario The scenario contained unrealistic values for Reactor Coolant System hot
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leg, Reactor Coolant System cold leg, containment temperature, and core exit thermocouples. For example, the Reactor Coolant System hot and cold leg temperatures should have exceeded 1000 degrees fahrenheit during the core melt scenario, but neither exceeded 550 degrees fahrenheit following the reactor tri _ _ _ _ _ - _ _ _ _ _.
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f-13-Prior to the exercise, several late changes were made in the scenario
packages involving radiation monitor data. These changes were not sufficiently controlled or disseminated. As a result, corresponding changes were not made in the simulator batch files. This led to the simulated scenario differing from the latest scenario data package.
6.1.2 Exercise Control During the event, Safety injection flow was throttled at about 2:10 p.m.
- The effects of throttling the safety injection flow was not reflected in the refill rate that was used in the event. When the safety injection flow was throttled, the refill rate should have been slowed from the original rate in the scenario by the controllers; however, it was not.
The simulator failed multiple times at the same point of the scenario.
- Following the simulator failures, the controllers failed to take positive control of the running of the event, failing to promptly determine when to transition to the printed scenario data, and after the i
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determination was finally made, failing to make this decision known to all of the players and controllers in the facilities.
The controllers gave conflicting information on the radiation data.
- This involved having independent uncoordinated sources of information in the Control Room, Emergency Operations Facility, and Technical Support Center for the containment area wide range radiation monitor readings.
I Conflicting information was used in assessing the radiological consequences of the accident.
l Prior to simulator resets, announcements were not made to all Technical
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Support Center personnel by the controllers.
Examples are that as
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containment radiation readings went from 1300 to 4.5 R/hr, the Emergency Notification System Communicator informed the Duty Emergency Director when auxiliary building simulator radiation alarms were inadvertently cleared by simulator operators, as well as when the loss of NB02 bus
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occurred, and the simulator was reset. This resulted in player confusion with some players continuing actions on prior data / conditions until corrected by another player or until the player questioned the
data / condition.
Controllers had to make ad hoc corrections to scenario data during the
exercise, because the scenario condition did not match plant conditions.
An example was at 11:04 a.m. when a Controller corrected data just
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previously given to the Chemical Coordinator by another Controller which was for the right time frame but for the wrong containment radiation-levels.
There appeared to be some pre-exercise anticipatory action in that two
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mechanics were in the Operational Support Center waiting for the start of the exercise, and the Operational Support Center emergency plan.
supply lockers were unlocked 30 minutes prior to the start of the exercise.
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-14-Onsite ' team No. 6 was initially briefed in the Operational Support
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Center on Auxiliary Building 2047 radiation levels at 10 R/hr.
During the briefing, radiation levels were reported to be dropping rapidly, and -
team No. 6 was advised to expect levels at approximately 130 mrem /hr.
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In the field, the controller provided radiation levels at 10-130 R/hr,.
and an increase from 12 R/hr inside the door just outside the
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. containment personnel access hatch to 130 R/hr just inside this same door. This door would never provide this much shielding. Also, these levels were not consistent with the levels reported during the initial briefing.
6.1.3 Simulation The simulator data for some of the radiation monitors did-not match the
data sheets and drill scenario.
At 11:15 a.m., it was noted that containment temperature was 383*F with
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pressure at 21 psig. Containment saturation temperatures at'21 psig
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occurs at approximately 259 F.
The Technical Support Center Status Board was updated after conferring with the Control Room.
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Hydrogen concentration after the burn remained at 0.5. percent throughout.
- the remaining portion of the exercise, rather than rising as would be expected under the exercise conditions.
At 10:30 a.m., when the Reactor Coolant Pumps were restarted, a loss of l
Engineering Safety function Bus NB02 occurred. The scenario did not call for a loss of NB02.
At 10:36 a.m., the Emergency Notification System Communicator informed
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the Duty Emergency Director that all Auxiliary. Building radiation
monitors were in alarm. The scenario did not call for these radiation
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monitors to be in alarm at this time.
The above problems with the scenario, exercise control, and simulation were identified as an exercise weakness (482/9320-06).
6.2 Conclusion i
a An exercise weakness was identified in the areas of exercise preparation and u
Control.
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l 7 LICENSEE SELF-CRITIQUE (82301-0302.b.12)
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The inspectors observed and evaluated the licensee's formal self-critique on December 3,1993, to determine whether the process would identify and characterize weak or deficient areas in need of corrective action.
7.1 Discussion
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-15-L The licensee described its critique process as involving all players,
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evaluators, and representatives of senior management and were discussed in considerable breath and depth.
Licensee findings were characterized.in terms similar to NRC findings.
The licensee identified exercise weaknesses which were also identified by the inspectors in this report even though some were.
i grouped differently.
In addition, the licensee's critique process identified an exercise weakness not identified by the NRC team regarding the failure to
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pass all required information to the state via Message CR-001.
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7.2 Conclusion The licensee's critique was good and properly identified weak areas in need of
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corrective action.
In addition to the general weakness categories identified by the NRC. team, the licensee's critique identified an additional exercise weakness that was not found by the inspectors. The licensee's grouping of weak areas was different from that of the inspection team, but was adequate;
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ATTACHMENT 1 PERSONS CONTACTED
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l 1.1 Licensee Personnel
- N. S. Carns, Chief Executive Officer
- M. Blow, Health Physicist l
- A. B. Clason, Supervisor, Maintenance Engineering
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- K. D. Craighead, Emergency Planning Specialist III
- J. Dagenette, Emergency Planning Specialist
- T. M. Damashek, Supervisor, Quality Assurance Surveillance
- B. Dunlap, Regulation Compliance
- T. F. East, Supervising Instructor, Chemistry
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- R. C. Hagan, Vice President, Nuclear Assurance
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- R. Hammond, Health Physicist
- L. S. Herhold, Supervisor, Emergency Planning l
- C. J. Holman, Quality Assurance Specialist III
- S. Holman, Supervisor, Health Physics
- D. M. Hooper,. Engineering Specialist, Licensing
- 0. Maynard, Vice President, Plant Operations
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- B. McKinney, Manager, Operations
- K. J. Moles, Manager, Regulatory Services
- J. D. Pappan, Quality Assurance Specialist III
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- D. Parks, Supervisor, Corporate Training
- E. Peterson, Supervisor, Audits / Quality Assurance
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- T. L. Riley, Supervisor, Regulatory Compliance
- M. A. Schreiber, Supervisor, Onsite Emergency Planning I
- C. Stone, Quality Assurance Specialist III
- S, S. Teal, Emergency Planning Specialist
- D. Webb, Simulator Specialist II
- D. Wiltse, Shift Supervisor, Emergency Planning
- B. K. Winzenrie, Engineer, Emergency Planning L
- C. Younie, Shift Supervisor 1.2 NRC Personnel
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- G. Pick, Senior Resident Inspector
- Denotes those present at the exit meeting i
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l 2 EXIT MEETING l-The inspection team met with the licensee representatives indicated in
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Section 1 of this Attachment on December 3, 1993, and summarized the scope and l
findings of the inspection as presented in this report.
The licensee did not
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identify as proprietary any of the materials provided to, or reviewed by, the
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inspectors during the inspection.
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