IR 05000498/1993017
| ML20045D810 | |
| Person / Time | |
|---|---|
| Site: | South Texas  |
| Issue date: | 06/25/1993 |
| From: | Murray B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20045D801 | List: |
| References | |
| 50-498-93-17, 50-499-93-17, NUDOCS 9306300086 | |
| Preceding documents: |
|
| Download: ML20045D810 (20) | |
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APPENDIX U.S. NUCLEAR REGULATORY COMMISSION l
REGION IV
Inspection Report:
50-498/93-17 50-499/93-17 l
Operating Licenses: NPF-76 NPF-80 Licensee: Houston Lighting and Power Company P.O. Box 1770 Houston, Texas 77251 Facility Name: South Texas Project Electric Generating Station Inspection At: Matagorda County, Texas Inspection Conducted: June 7-10, 1993 l
Inspectors:
D. Blair Spitzberg, Ph.D., Team Leader W. Holley, C.H.P., Senior Radiation Specialist J. Keeton, Senior Reactor Engineer Accompanying Personnel:
D. Schultz, Comex Corporation C. Stephens, Entek, Inc.
L d 2-D Approved:
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M B. Murray, pief, Facilities Inspection Dat'e Y
Programs section Inspection Summary Areas Inspected: Routine, announced inspection of the licensee's performance and capabilities during an annual exercise of the emergency plan and implementing procedures. The inspection team observed activities in the control room (simulator), Technical Support Center, Operational Support Center, and the Emergency Operations Facility.
Results:
Strong command and control were observed in the control room in response
to plant transients and the early scenario events.
Emergency classifications and notifications were made in an accurate and timely manner by the control room staff (Section 2.1).
The area of radiological assessment was noted to be a strength in the
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Technical Support Center (Section 3.1).
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conditions corresponding to a General Emergency (Section 3.1).
Licensee performance in providing technical assessment, diagnosis, and
mitigative activities was identified as an exercise weakness (Section 3.1).
Insufficient administrative staffing in the Technical Support Center and
the failure to obtain additional :taffing or to reassign the missing staff's responsibilities were identified as an exercise weakness (Section 3.1).
The actions taken by the Operational Support Center to support in-plant
teams and to protect radiation workers were found to be effective (Section 4.1).
An exercise weakness was identified for unnecessary delays noted in
providing proper treatment for the victim of a medical emergency and in removing the victim from the site by ambulance (Section 4.1).
The post accident sampling team was effective in simulating the safe
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acquisition of coolant and containment atmosphere samples (Section 4.1).
The Emergency Operations Facility was activated in an efficient and
timely manner and performed well during the exercise. The performance of the radiological / dose assessment group was noted to be a strength
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(Section 5.1).
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A repeat exercise weakness was identified for several problems
associated with the issuance of complete and accurate notification messages (Section 6.1).
The exercise scenario provided a sufficient challenge to evaluate major
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exercise objectives (Section 7.1).
The licensee self-critique process failed to identify or properly
characterize several areas in need of corrective action and was,
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therefore, identified as an exercise weakness (Section 8.1).
Two potential areas for emergency response procedure improvement were
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discussed with licensee representatives (Section 9.1).
Sumraary of Inspection Findinas:
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Exercise weakness (498/9317-01; 499/9317-01) was opened (Section 3.1).
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Exercise weakness (498/9317-02; 499/9317-02) was opened (Section 3.1).
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Exercise weakness (498/9317-03; 499/9317-03) was opened (Section 3.1).
- Exercise weakness (498/9317-04; 499/9317-04) was opened (Section 4.1).
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Exercise weakness (498/9317-06; 499/9317-06) was opened (Section 8.1).
- Exercise Weakness (498/9209-03; 499/9209-03) was closed (Section.10.4).
Exercise Weakness (498/9209-04; 499/9209-04) was closed (Section 10.5).
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Exercise Weakness (498/9209-05; 499/9209-05) was closed (Section 10.6).
- Exercise Weakness (498/9120-05; 499/9120-05) was closed (Section 10.7).
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Attachment - Persons Contacted and Exit Meeting
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DETAILS 1 PROGRAM AREAS INSPECTED (82301)
The licensee's annual emergency preparedness exercise began at 1:30 a.ia. on
June 8, 1993. The exercise start time had been withheld from exercise l
participants. The exercise was an off-year exercise and did not include l
participation by offsite organizations. The exercise was not evaluated by the Federal Emergency Management Administration. The exercise scenario centered around Unit I with the simulator being used as the Unit I control room. A loss of the electrical auxiliary building heating, ventilation, and air conditioning resulted in high ambient temperatures in the electrical auxiliary building which caused sequential failure of the emergency buses. The problem was complicated by a loss of auxiliary feed water, a reactor coolant pump seal failure, and a loss of coolant accident. This required event classification
escalating to a General Emergency. The scenario included an offsite radiological release and a simulated heat stroke / injury victim.
The inspection team identified various concerns during the exercise; however, none were of the significance of a deficiency as defined in 10 CFR 50.54(s)(2)(ii).
Each observed concern can be characterized as an exercise weakness or as an area recommended for improvement. An exercise 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 corrective action.
Other observations are documented which did not have a significant negative impact on overall performance during the exercise but still should be evaluated and corrected as appropriate by the licensee.
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 j
corrective measures, notifications of offsite authorities, and adherence to the emergency plan and implementing procedures.
2.1 Discussion The control room staff was observed to identify and classify plant conditions in an accurate and timely manner during the period when emergency command and control authority rested in the control room. The declaration of the Unusua'.
Event and Alert were properly based on control indications existing at the time. All notifications to offsite agencies that were made from the control room were timely and accurate.
Command and control from the control room were strong in response to plant transients and the early scenario events.
Early into the scenario, the Duty Operations Manager reported to the control room and assisted the Shift Supervisor / Emergency Director in supervising operations and acting in an advisory capacity.
This was a noted strength in the emergency organization.
During the turnover of Emergency Director responsibilities from the Shift w
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Supervisor to the Technical Support Center Manager, plant conditions degraded
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to the point that required declaration of a Site Area Emergency. The Shift Supervisor (Emergency Director) was careful not to turn over command authority to the Technical Support Center until he was convinced that the immediate plant conditions were understood in the Technical Support Center and that the escalation would be properly executed from the Technical Support Center.
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Despite the good communications of the plant conditions existing at the time,
the control room staff did not effectively assimilate plant and equipment
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status for the first hour and a half of the scenario. This observation is discussed in greater detail in Section 3.1 as part of an exercise weakness in the area of technical assessment, diagnosis, and mitigative activities, s
Operational assessments made from the control room by the operators were essentially correct; however, random assessment errors did affect scenario progression and mitigation. The most notable example was the apparent failure of the control room supervisors to recognize that the elevated ambient temperature in the electrical and mechanical building spaces was the primary cause of electrical equipment failures.
This was evident when the auxiliary operator returning to the control room from the effected spaces reported high heat levels. The supervisors questioned if there was evidence of a fire but neither addressed the habitability issue nor did they appear to connect the cause of failures.
2.2 Conclusions Strong command and control were observed in the control room in response to plant transients and the early scenario events. Emergency classifications and notifications were made in an accurate and timely manner by the control room staff.
3 TECHNICAL SUPPORT CENTER (82301-03.02.b.2)
The inspection team observed and evaluated the Technical Support Center staff as they performed tasks in response to the exercise scenario. These tasks included detection and classification of events, notification of Federal, State, and local response agencies, analysis of plant conditions, formulation of corrective action plans, briefing of repair teams, and protective action decisionmaking and implementation.
3.1 Discussion The inspectors noted that the Technical Support Center was activated about I hour after the Alert declaration. Throughout the exercise, the area of radiological assessment was noted to be a strength in the Technical Support Center. As one example, the Security Manager, after conferencing with the Radiological Manager, repositioned Security Officers positioned in the footprint of a potential radiological release, although no such release was in progress nor expected at the time. A second example was the action of the Technical Support Center Radiation Monitoring System (RM-ll) Operator during the exercise.
In particular, during the process of command turnover from the control room to the Technical Support Center when plant conditions were changing rapidly, increasing containment radiation monitor readings were
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i-6-immediately noted by the RM-ll operator as exceeding an Emergency Action Level.
Recognition of this resulted in a classification of a Site Area Emergency. The radiological assessment group was also observed to be proactive in localizing the radiological release pathway. As a result, a recommendation to Operations was formulated by the Radiological Manager that when executed, terminated the release.
While the Technical Support Center held emergency command and decisionmaking authority, degrading plant conditions reached conditions for an imminent declaration of a General Emergency. The Technical Support Center did not recognize or assess properly the severity of these conditions. At 1:45 a.m.
essential Bus ElC was lost to fault; at 3:20 a.m. essential Bus EIA was lost to fault; and at 3:35 a.m., essential Bus ElB was lost to fault.
This final loss resulted in a loss of engineered safety feature functions due to a total loss of AC on essential 4160 V buses.
Further compounding the plant threat, at 3:20 a.m. the turbine driven auxiliary feedwater pump was lost due to a loss of the turbine governor control valve.
By this time, the plant had an ongoing loss of coolant accident that had initiated at 1:45 a.m. and had increased in severity.
In addition, the loss of all essential AC power resulted in no primary injection and no secondary cooling. Thus, the plant had effectively entered a core melt sequence.
During this period, the Technical Support Center escalated the emergency classification from an Alert to Site Area Emergency at 3:40 a.m. based on reactor containment building radiation levels.
Bus ElC was not recovered until 4:25 am.
Procedure OERP01-ZV-IN01, Revision 1, " Emergency Classification," did not explicitly address in the emergency action levels contained in Addendum 1, the specific plant conditions postulated by the scenario.
Step 5.5 of the procedure recognizes, however, that all possible emergency conditions will not be specifically addressed. This step provides for an emergency to be declared at any level based on the judgement of the Emergency Director, even if it is not specifically covered in Addendum 1.
Further, Step 2.8 defines General Emergency as events in progress or have occurred which involve actual or imminent substantial core degradation or melting with potential for loss of containment integrity. Given the plant conditions after 3:35 a.m., neither the Emergency Director nor the Technical Support Center staff indicated that they recognized the severity of the conditions.
Failure to recognize General Emergency conditions was identified as an exercise weakness (498/9317-01; 499/9317-01).
The inspection team observed weak licensee performance during the exercise in providing technical assessment, diagnosis, and mitigative activities.
NUREG-0696, " Functional Criteria for Emergency Response Facilities," defines in paragraph 1.3.1 that the Technical Support Center shall provide plant management and technical support to reactor operating personnel, shall assist in detailed analysis and diagnosis of abnormal plant conditions, shall be the primary communications center for the plant, and shall assist control room operators by handling technical evaluations. With respect to the general tasks responsibilities of the Technical Support Center, the following examples of weak performance were noted:
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l The control room staff did not effectively assimilate plant and
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equipment status information for the first hour and a half of the event.
As a consequence, the Technical Support. Center staff on receiving briefings from control room personnel neither understood the magnitude of degraded plant conditions nor the reasons for the degradation on assuming command and control 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> into the event.
Although some repair and corrective actions were initiated by the
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Technical Support Center in response to scenario events and actions were reprioritized on a regular basis, the efforts were not always effective in mitigating the consequences of the accident.
In addition, feedback from the field did not result in the Technical Support Center increasing its understanding of the extent of equipment problems. Several equipment failures were not properly assessed for their operational impact and, as a consequence, the Technical Support Center was unable to formulate mitigative strategies to lessen the impact of the equipment losses. Rather, the Technical Support Center was mostly in a plant status tracking mode and gave evidence that even this task was not performed well.
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At 1:35 a.m. (5 minutes into the exercise), the B. train electrical
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auxiliary building heating, ventilation, and air conditioning supply fan tripped due to shedding impellers. This event necessiated startup of Train C heating, ventilation, and air l
conditioning. At 1:45 a.m. the C train essential cooling water
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pump motor grounded due to a cooling water leak. The pump motor I
breaker failed to trip due to a breaker fault, thus the essential load center ElC feeder breaker tripped. This load center loss resulted in loss of C Train engineered safety feature functions, and C train heating, ventilation, and air conditioning. The inspectors noted that diagnosis of the loss of ECW Pump C did not begin until approximately 5:35 a.m. when the Maintenance Manager ordered the pump motor to be meggered.
The Maintenance Manager had been under the impression that meggering had already occurred earlier, that the motor was faulted, and that the fault could not be corrected. The simulated fault was a broken seal water line that sprayed water into the pump motor.
This problem could have been corrected by flushing of the motor with demineralized water.
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At 2:15 a.m. high area temperature alarms began occurring for various electrical auxiliary building switchgear rooms because only A train heating, ventilation, and air conditioning was operating but in a very degraded condition due to plugged cooling coils.
This was a preexisting condition that previously went unnoticed due to the performance of Train B which later failed.
About 45 minutes later, a repair team member suffered a heat stroke in the Elc switchgear room and a spurious overcurrent trip occurred on load center E1A2 feeder breaker.
Subsequently, several other equipments spuriously tripped (e.g., B train essential chill water pump, A train component cooling water pump).
As late as 3:25 a.m., the Security Manager reported high temperatures in the electrical auxiliary building room to the
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-8-Assistant Technical Support Center Manager, but no action was taken.
Notwithstanding these significant, multiple equipment faults and indications, not until 4:25 a.m. was any mention of relay target positions made by the Technical Support Center engineering group.
Not until about 4:59 a.m. did the engineering group become aware that the electrical auxiliary building room temperatures had i
increased to about 125 degrees Fahrenheit and began to recognize a
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common fault failure mechanism.
At 4:38 a.m. one Technical l
Support Center staff manager commented at a Technical Support Center Manager's meeting that since there was no power on the buses, it did not make sense that the switchgear rooms were hot.
No troubleshooting plan was formulated by the Technical Support
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Center to determine the relay and breaker failure. meanings or l
their causes. As a consequence, no recognition was made by the Technical Support Center staff of the impact of total loss of the
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electrical auxiliary building heating, ventilation, and air conditioning. Further, no mitigative strategies such as temporary
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ventilation were developed to lessen the impact of loss of ventilation and restore engineered safety feature functions.
No actions on the part of Technical Support Center staff were performed that resulted in the restoration of the A and B train buses at about 5:30 a.m.
These buses were restored as a result of the scenario time line, not because of any positive action taken l
by the response organization.
In fact, at 5:38 a.m., the Technical Support Center Manager was advised by a discipline
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manager that it was unknown how essential Buses A and B had been restored.
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At 4:10 a.m., the Operational Support Center reported to the Technical Support Center that Train C power was ready for restoration. At 4:20 a.m. Train C was energized. No recognition was made by Technical Support Center staff that Train C engineered safety feature components were being operated without essential cooling water because ECW Pump C; Train C heating, ventilation, and air conditioning; and essential chilled water had not been
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l restored. As a consequence, Train C engineered safety feature l
components were operated without adequate cooling ventilation for l
an extended period up to the conclusion of the exercise at 6:30 a.m.
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Technical Support Center status boards were not always accurate or up-to-date. For example, the Equipment Out-of-Service Status Board reflected only the four items listed below for the entire accident sequence up to 6:45 a.m.:
C train engineered safety feature switchgear 480 V load center EIA2 i
l Auxiliary feedwater pump D A & B engineered safety feature switchgear
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-g-Because of inaccurate status boards, Technical Support Center managers were hampered in their ability to determine accurately the actual plant status and the significance of events.
Based on the examples cited above, licensee performance in providing technical assessment, diagnosis, and mitigative activities was identified as an exercise weakness (498/9317-02; 499/9317-02).
The inspectors noted that the Technical Support Center was declared
" activated" about 60 minutes after the Alert declaration. The positions of the Administrative Manager and staff were absent from the Technical Support Center until at least 6 a.m.
While these are not identified as required positions, the absences adversely impacted the ability of the Technical Support Center to conduct effectively critical response activities.
Procedure OERP01-ZV-IN03, Revision 4, " Emergency Response Organization Notification," required in Step 7 of the Emergency Response Organization Activation Checklists that the Acting Operational Support Center Coordinator / Assistant Operational Support Center Coordinator, " Contact a responder for each ERO position that did not respond to the Emergency Notification Response System." Apparently, this activity did not occur for the absent Administrative Manager and staff.
Procedure OERP01-ZV-TS01, Revision 4, "TSC Manager," Alert Checklist, Step A.2., required the Technical Support Center Manager to, " Confer with the Administrative Manager on the current staffing of the Technical Support Center ano Operational Support Center," and "If any Manager has not arrived within approximately 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> of the initial callout, THEN assign their assistant or a staff member to implement the absent manager's procedure." The inspectors observed that the actions required by this procedure were not completed by the Technical Support Center Manager or his designee. As a consequence, none of the activities required by Procedure OERP01-ZV-TS09, Revision 2, " Administrative Manager,"
were formally completed, such as the responsibility for monitoring personnel fitness-for-duty, preparation of relief shift schedules, distribution of event related communications, and records to Technical Sur port Center staff or
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arrangement for food services.
The failure of two procedures to be implemented fully by response facility managers resulted in a failure to fully staff the Technical Support Center with designated administrative management and staff.
In addition, administrative staff functions were not reassigned. The inspectors concluded that these failures contributed to the problems the Technical Support Center experienced in providing effective technical support.
Insufficient staffing of the Technical Support Center was identified as an exercise weakness (498/9317-03; 499/9317-03).
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l 3.2 Conclusions The area of radiological assessment was noted to be a strength in the l
Technical Support Center. An exercise weakness was identified for failure to recognize plant conditions corresponding to a General Emergency.
Licensee performance in providing technical assessment, diagnosis, and mitigative activities was also identified as an exercise weakness.
Insufficient
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4 OPERATIONAL SUPPORT CENTER (82301-03.02. b.4)
The inspect 3rs evaluated the performance of the Operational Support Center staff as they performed tasks in response to the exercise. These tasks included activation of the Operational Support Center and its effectiveness in providing support to operations, including the coordination of emergency in-plant response teams.
4.1 Discussion The Operational Support Center was staffed and activated within an hour after the ALERT was declared. Upon activation, the facility was fully functional.
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The inspectors noted that operational checklists were used effectively in the l
facility. Communications between the Operational Support Center and the l
Technical Support Center were observed to be clear. Surveys were periodically l
performed to ensure continued habitability.
The facility staff was kept well informed of the emergency status of the plant and maintained order in the
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facility's small, crowded space. The coordinator was thorough in his briefings to the staff and augmented his briefings with information provided
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by the health physics staff. Throughout the exercise, emergency response
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teams were briefed effectively by maintenance and health physics personnel.
A total of 17 in-plant teams were dispatched during the exercise. The status and progress of the teams were tracked effectively.
The inspectors observed the performance of a licensee medical re;ponse team during a medical scenario in which an individual passed out from elevated temperature and sustained a head wound when he fell. The simulated victim was unconscious and flushed when discovered, and his head wound was bleeding.
The first emergency team member arrived 7 minutes after the presence of the injury victim was reported. Throughout the incident, the injury victim was monitored for vital signs and was examined for other wounds in addition to the head wound. The following unnecessary delays were noted in providing proper response to the victim of the simulated medical emergency:
Eleven minutes elapsed after the first emergency medical team member
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arrived at the scene of the accident before an attempt was made to cool the injured person. At this time, cool packs were applied to his chest.
During the entire drill, no articles of clothing were removed or simulated to be removed from the victim to cool him.
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Thirty minutes elapsed from the time the injured person was discovered l
e until he was removed from the elevated temperature area.
j While waiting for the ambulance to wrive, the injured person was placed e
in the narrow entry / exit of the Unit I reactor building.
In this area, it was difficult to monitor the patient because of the personnel traffic through the passagewa l
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exercise, the inspectors learned that part of this delay was the result l
of the ambulance driver not being initially successful at starting the j
ambulance. The reason for this was his lack of awareness of a switch l
used to disconnect the vehicle battery leads to prevent loss of charge.
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In addition, several minutes were unnecessarily lost because the driver j
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to exit the site.
In all, over an hour elapsed from the time the injured person was
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discovered until he was taken by the ambulance from the site.
Unnecessary delays in providing proper treatment for the victim of a medical emergency and in removing the victim from the site by ambulance was identified i
as an exercise weakness (498/9317-04; 499/9317-04).
The inspectors observed the simulated acquisition of primary coolant and j
containment atmosphere samples utilizing the post accident sampling system.
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The post accident sampling system team consisted of a lead technician, two
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chemistry technicians, and a health physics technician. The post accident i
sampling system team was adequately briefed of task requirements and the possible hazards involved. Good radio communications were maintained with the Operational Support Center during the operation.
Throughout the sampling activities there was good health physics coverage.
The surveys and their frequencies were adequate. The health physics technician kept the post accident sampling system team well informed of the radiological conditions that were encountered.
The simulated radioactive samples were transported by hand in heavily shielded containers to the hot laboratory for analysis. The inspectors noted that the i
shielded containers were very heavy and could pose a problem for a person of
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average strength to carry.
4.2 Conclusions The actions taken by the Operational Support Center to support in-plant teams and to protect radiation workers while they accomplished their tasks were effective. An exercise weakness was identified for unnecessary delays noted in providing proper treatment for the victim of a medical emergency and in removing the victim from the site by ambulance. The post accident sampling team was effective in simulating the safe acquisition of coolant and containment atmosphere samples.
5 EMERGENCY OPERATIONS FACILITY (82301-03.02.b.3)
The inspection team observed 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, protective action decisionmaking, notifications, and interactions with offsite field monitoring teams.
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-12-5.1 Discussion The Emergency Operations Facility was observed to be staffed and activated within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> of the site area emergency classification.
Staff performance in the Emergency Operations Facility was efficient and effective overall.
The inspectors noted that access control to the Emergency Operations Facility was informal. Although the Emergency Operations Facility staffing board indicated a position for Emergency Operations Facility access control, this position was stricken by a staff member several hours into the exercise.
Sign-in logs were placed at the Emergency Operations Facility access point and the entrance was monitored by staff. No security personnel were assigned to the Emergency Operations Facility access point. The inspectors noted that facility habitability checks were performed periodically throughout the exercise, and monitoring equipment and a contamination control point were established at the entrance to the Emergency Operations Facility.
The inspectors noted, however, that no container for used anti-contamination articles was present. Potentially contaminated items of protective clothing were left on the floor outside the step-off pad.
Staff communications, face-to-face and by telephone, were observed to be informal throughout the exercise.
Repeat back commands were used infrequently, and the phonetic alphabet was not utilized. The only observed exception was the Dose Assessment Specialist who used repeat backs of critical information in his communications. Status boards in the Emergency Operations Facility were observed to be maintained current and accurate throughout the l
exercise. The Emergency Operations Facility Support Organization Director and staff were observed to make effective arrangements, both simulated and actual,
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for logistical support items including vendor, INPO, transportation, relief personnel, and food supply support.
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As noted in the Technical Support Center, the radiological / dose assessment group in the Emergency Operations Facility was a licensee strength during the l
exercise. Dose projections were observed to be timely and accurate.
Offsite monitoring teams were observed to be effectively controlled and coordinated in i
their sampling efforts.
Information from offsite monitoring teams was periodically compared to expected conditions based on computerized dose l
projections.
The radiological staff and the dose assessment staff were observed to be consistently aggressive in following and interpreting plant status relative to emergency classification and potential protective action recommendations.
For example, the Dose Assessment Specialist observed a decrease in containment pressure about 4:45 a.m. and informed the Radiological Director that containment pressure was on the verge of meeting a general emergency classification. Shortly thereafter, the controller network injected l
a different, higher containment pressure value into the scenario play necessitated by the transition between simulator real-time data and the backup l
data set from previous simulator runs. This was one of several noted examples of the aggressive actions of the dose assessment staff in monitoring plant statu._ _
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-13-5.2 Conclusions The Emergency Operations Facility was activated in an efficient and timely j
manner and performed well during the exercise. The performance of the radiological / dose assessment group in the Emergency Operations Facility was noted to be a strength.
6 NOTIFICATIONS (82301)
During the exercise, the inspection team observed the process of making initial offsite notifications and the issuance of followup notification messages.
6.1 Discussion Initial notification messages and followup messages were made from the control room, Technical Support Center, and Emergency Operations Facility. depending upon which facility maintained emergency command authority at the time the message was issued.
Initial notifications following each classification were observed to be made in a timely manner.
Instances of incorrect information on notifications messages and other notifications related problems included the l
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Message 3 was not released. The Technical Support Center staff prepared
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Message 3 as a followup message to the Alert declaration. On presentation of the message to the Technical Support Center manager for release, the staff was advised that.the control room still.had command and control. Thus, Message 3 was held in abeyance. The Technical Support Center Manager advised the control room that the control room had the responsibility for the message. Events then overcame message preparation and the Technical Support Center assumed command and control and prepared the Site Area Emergency declaration message as Message 4 which was released at 3:46 a.m.
As a consequence, offsite facilities would have been uncertain whether a potential loss of a message had occurred.
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Procedure OERP01-ZV-IN02, " Notifications to Offsite Agencies," requires
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in paragraph 5.1.3. that the licensee, " Issue followup notifications to l
offsite agencies on an hourly basis...." The Alert message was issued at 2:22 a.m.
No followup message was-issued by the control room prior to 3:22 a.m.
The next message was No. 4 issued at 3:46 a.m.,
some 24 minutes after the required follow"p message issue time.
Messages 4 contained errors that could lead to significant e
misinformation and confusion among message recipients as follows:
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Although containment pressure was greater than two psig at 3:40 a.m., Block 5, " Radiological release in progress" was checked "No" vice " Potential." This error was propagated in Messages 5 and 6.
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The Site Area Emergency classification was based on the fuel clad barrier loss Emergency Action Level 3, " Reactor Containment l
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than or equal to 50 R/hr," and the Reactor Coolant System barrier I
loss EAL 2, " Reactor Coolant System leakage greater than the I
capacity of available Charging Pumps." Contrary to the classification action levels, however, message Block 7. " Event description," was only checked " Reactor Coolant System Breach."
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" Fuel Element Breach" was not checked. The written explanation j
denoted in message Block 7. stated, "High rad in RCB >50 R/hr
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(actual 143 R/hr)," but did not state the high reading was a
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combination of high coolant activity and Reactor Coolant System breach. This error was propagated in Message 5.
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Message Block 8, " Meteorological data," was not completed although l
the inspectors noted there was sufficient time to provide this informati on.
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Message 5 issued at 4:03 a.m. contained a protective action a
recommendation as a followup to the Site Area Emergency declaration communicated in the previous-message.
Block 8, " Meteorological data,"
was checked, " Unchanged," although meteorological data had not previously been forwarded to offsite authorities.
Message 5 contained several errors of omission' including:
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Block 2 had no option checked to indicate that it was a drill i
message.
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Block 6.C. had no block checked to indicate whether the Bureau of i
Radiation Control had been contacted or concurred with the l
protective action recommendations.
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Block 7 lacked the actual value for high radiation in the reactor containment' building that was provided.in Message 4.
This could i
l have resulted in the erroneous interpretation that the level at j
l the time of message issuance was the emergency action level shown (>50 R/hr).
Message 6, the first to be prepared in the Emergency Operations
Facility, Block 6.C, " Bureau of Radiation Control (BRC) concurs with recommendations:," was checked in boxes indicating both "No" and "BRC Not Contacted." This practice continued through the remaining messages during the exercise. This indicated differing understandings of the proper procedure for completing notification forms.
Message 7 Block 6.A, was checked to indicate that protective action
recommendations were not being made at that time.
Block 6.B was also checked to indicate that Protective Action Recommendations were being issued, and what they were. During verbal transmission of this message to offsite agencies, the Err ency Operations Facility's communicator noted this discrepancy. The communicator then consulted with the Technical Director who checked Block 6.B.
He did not line-out the
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incorrectly checked Block 6.A.
The communicator then completed the l
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i-15-verbal notifications. A similar sequence of events, involving the same staff members, occurred with Message 8 with the addition of a check mark in Block 9.A.
Procedure OERP01-ZV-IN02, " Notification to Offsite Agencies," Step 4.1 states, "The individual with Emergency Director authority is responsible for approving all notifications to offsite agencies and...." The above changes made to the completed notification form were not approved by the Emergency Director.
Message 7, Block 9.A., indicated an expected release duration of
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8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />. At that time, the leak pathway was unknown; therefore, there was no basis for that period of expected release duration.
The above examples of problems associated with issuance of complete and accurate notification messages was identified as an area of repeat exercise weakness (498/9317-05; 499/9317-05).
6.2 Conclusions A repeat exercise weakness was identified for several problems associated with i
the issuance of complete and accurate notification messages.
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7 SCENARIO AND EXERCISE CONDUCT (82301)
The inspection team made observations during the exercise to assess the l
challenge and realism of the scenario and to evaluate the conduct of the l
exercise.
7.1 Discussion The initial exercise scenario submitted April 1,1993, was determined by NRC to be lacking sufficient challenge to evaluate effectively certain performance areas identified in the exercise objectives and previous exercise findings.
As a result, the licensee submitted a modified scenario on May 18, 1993. This scenario which was used for the exercise was observed to provide sufficient challenges to demonstrate major objectives. The recovery related objectives, however, were unrealistic for the length of the exercise. The inspectors also noted that exercise scenario objectives lacked evaluation criteria.
7.2 Conclusions The exercise scenario provided sufficient challenge to evaluate major exercise objectives.
8 LICENSEE SELF-CRITIQUE (82301-03.02.b.12)
The inspectors observed and evaluated the licensee's formal self-critique on June 10, 1993, to determine whether the process would identify and characterize weak or deficient areas in need of corrective actio l'
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l 8.1 Discussion The licensee described the process of self-critique and presented its findings. To be consistent with NRC practice, the licensee used the i
l terminology of " deficiency," " weakness," and " improvement item," to characterize findings according to their significance.
The self-critique l
process involved input by exercise players, evaluators and controllers, and l
licensee management.
I The licensee identified two weaknesses and seven improvement items in their i
critique. A weakness was identified for instances of poor communications.
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Three examples were contributory to this weakness including two erroneous reports of the status of essential electrical equipment and an example of miscommunication of a task assigned to an Operational Support Center repair team. The second weakness involved weak Technical Support Center engineering staff problem solving.
This weakness contained some contributory examples that were similar to elements of the NRC-identified exercise Weakness 498/9317-02; 499/9317-02 described in Section 3.1.
Among the improvement items identified by the licensee were the ambulance response time, exercise controller actions to control changing scenario conditions, emergency response organization notification process, and Emergency Operations Facility access control.
The inspection team noted that the licensee did not identify several of the
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l findings made by the NRC inspection team as requiring corrective action. Most notable was the absence of any discussion in the licensee's critique
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pertaining to the NRC-identified weakness in the area of identifying general emergency conditions.
In addition, the licensee characterized as improvement items some of the findings that the NRC team assessed as weaknesses requiring corrective action.
For example, the ambulance response time was characterized by the licensee as an improvement item, despite the potential implications of the slow response. Another example was a licensee improvement item related to notification messages which identified only two of the notification problems cited in Exercise Weakness 498/9317-05; 499/9317-05 described in Section 6.1.
l In consideration of the licensee's self-critique results, the inspection team
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l concluded that the critique process did not identify or appropriately characterize several findings requiring corrective action. Consequently, the
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licensee's self-critique process was identified as an exercise weakness (498/9317-06; 499/9317-06).
8.2 Conclusions The licensee self-critique process failed to identify or properly characterize several areas in need of corrective action and was, therefore, identified as an exercise weakness.
9 PROCEDURE REVIEW In preparation for the exercise, the inspection team reviewed emergency response procedures.
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Procedure OERP01-ZV-IN01, Revision 1, " Emergency Classification."
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Listed in Addendum 1, " Fission Product Barrier Emergency Action Level (EAL) Table," the fuel clad barrier loss Emergency Action Level 3 was listed as, " Reactor Containment Building Accident Monitors RT-8050 or RT-8051 indicate greater than or equal to 50 R/hr." The exact same Emergency Action Leve! was listed as the reactor coolant system barrier loss Emergency Action Level 3.
The team was concerned that inaccuracies in these values may exist since the release of " normal" coolant activities (i.e., within Technical Specifications) to the containment should result in monitor readings that are two or three orders of magnitude below a similar release of failed fuel laden coolant to the containment.'
Procedure OERP01-ZV-IN07, Revision 3, "Offsite Protective Action
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Recommendations," required in Addendum 1, that for a Site Area Emergency with severe core damage or an imminent (within 1 to 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />) escalation to General Emergency, an evacuation within 5 miles and shelter between 5 and 10 miles protective action recommendation should be recommended to offsite authorities. This procedural recommendation was inconsistent with current published guidance of NRC. Current guidance states that for actual or projected severe core damage or loss of control of the i
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facility the protective action recommendation should be evacuation of a
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2 mile radius and 5 mile downwind unless conditions make evacuation dangerous and shelter remainder of plume emergency planning zone.'
9.2 Conclusion Two potential areas for emergency response procedure improvement were discussed with licensee representatives.
10 FOLLOWUP ON PREVIOUS INSPECTION FINDINGS 10.1 (0 pen) Violation (498/9114-01: 499/9114-01):
Failure to augment on-shift Emergency Response Organization within 45 to 60 minutes as reauired
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by the plan l
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- NUREG/BR-150, Vol.1, Rev. 2, " Response Technical Manual", Figure B-7.
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f-18-l 10.2 (0 pen) Unresolved Item (498/9210-01: 499/9210-01): Lack of sufficient
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information to establish whether the licensee could meet the Emeraency Response Organization staff augmentation timeliness specified in the Emergency Plan By letter dated May 20, 1993, the NRC approved a revision to the licensee's emergency plan that increased the amount of time allowed to augment the onshift Emergency Response Organization by 15 minutes.
In addition, since these inspection findings were opened, the licensee had revised the callout system to improve response times. The inspectors reviewed recent results of
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callout drills conducted and found that the licensee had fully met the previous augmentation timeliness criteria on 6 of the 10 drills conducted during 1993. On the four occasions that timeliness criteria was not met, the number of responders failing the response criteria was 2.
Reasons included j
pagers not going off or late response.
Since the response times have been
increased, the licensee has met augmentation criteria on one drill.
The inspectors observed that staff augmentation during the exercise also met the response criteria.
Because of mixed results prior to the plan revision, however, and with only two tests since, the NRC will need to review additional drill results in order to close this item. This matter will be reviewed further during the operational status inspection scheduled for August 2-6, 1993. The licensee plans to conduct two augmentation drills between this inspection and August 2,1993.
Based on the results of the two drills, a decision will be made regarding the status of the unresolved item.
10.3 (0 pen) Exercise Weakness (498/9209-01: 499/9209-01): This weakness was identified durina the 1992 exercise.
It resulted from two elements that. in combination, constituted a weakness.
The first element was failure to make timely offsite notifications.
The second element was
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incorrect information on the initial notification messaae for the site area emernencv.
During the 1993 exercise, initial notificationi following each classification were observed to be made in a timely manner. The first element of the weakness is closed. The inspectors reviewed corrective action to this weakness and found that all personnel involved in offsite notification message preparation and release received training that emphasized the need to review closely the offsite notification message for accuracy prior to releases.
While records indicated this training was performed, the inspection team found evidence that it was not sufficient to prevent a recurrence of similar notification problems.
During the 1993 exercise, the inspection team again noted several examples of notification inaccuracies, errors, omissions, or lack of proper approval.
This was identified as an area of repeat weakness (Section6.1).
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It resulted from an procedural inadecuacy reauirina concurrence from offsite authorities prior to makina protective action recommendations and a lack of procedural quidance as to what to do if that concurrence was not obtained.
The inspectors noted that Procedure OERP01-ZV-IN02, " Notification to Offsite Agencies," does not require obtaining concurrence from offsite authorities prior to making protective action recommendations.
10.5 (Closed) Exercise Weakness (498/9209-04: 499/9209-04): This weakness l
pertained to the lack of a method to properly Coordinate site evacuees to prevent exposure to radioactive hazards.
During the 1993 exercise, proper coordination efforts were observed to prevent exposure of site evacuees and station personnel.
Security personnel were effectively repositioned from their post-out positions to avoid potential exposures from the release.
10.6 (Closed) Exercise Weakness (498/9209-05: 499/9209-05):
This weakness was for several specific examples of improper medical treatment.
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During the 1993 exercise, the inspectors noted that the specific treatment
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problems noted during the previous exercise had been corrected.
10.7 (Closed) Exercise Weakness (498/9120-05: 499/9120-05): This weakness was identified durina the 1991 axercise for failure to include radioloaical precautions in public address announcements durina site evacuation.
During the 1993 exercise, the public address announcements issued clear instructions for site personnel to stand clear of the downwind direction of the affected unit.
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ATTACHMENT 1 PERSONS CONTACTED 1.1 Licensee Personnel
- C A. Ayala, Supervisory Iicensing Engineer
- L. S. Barton, Supervisory Emergency Planning Specialist l
- M. K. Chakravorty, Executive Director, Nuclear Safety Review Board
- K. J. Christian, Manager, Plant Operations
- W. T. Cottle, Group Vice President, Nuclear
- M. A. Coughlin, Senior Licensing Engineer
- H. A. Covell, Manager, Emergency Response
- J. R. Fast, Director, Maintenance Production
- R. P. Garris, Manager, Human Resources, Nuclear
- J. F. Groth, Vice President, Nuclear Generation
- S. M. Head, Deputy General Manager, Licensing
- W. H. Humble, Manager, Plant Programs
- T. J. Jordan, General Manager, Nuclear Engineering
- K. S. Kennedy, Emergency Planning Specialist
- W. H. Kinsey, Vice President, Plant Support
- B. A. Kruse, Senior Quality Assurance Specialist
- D. A. Leazar, Manager, Plant Engineering
- M. A. Ludwig, Manager, Training
- F. H. Mallen, Manager, Planning and Assessment
- R. T. Mayberry, Senior Staff Consultant, Emergency Planning
- T. A. Meinicke, Deputy Plant Manager, Projects
- M. S. Moneith, Superv'sor, Quality Surveillance
- G. L. Parkey, Plant Manager
- P. E. Parrish, Senior Specialist
- R. W. Pell, Manager, Health Physics
- K. M. Poling, Training Manager Assistant
- F. J. Puleo, Emergency Planning Specialist
- C. G. Walker, Manager, Public Information
- M. R. Wisenburg, Assistant to Group Vice President, Nuclear 1.2 NRC Personnel i
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- J. 1. Tapia, Senior Resident inspector
- D. Garcia, Reactor Engineer
- Denotes those present at the exit meeting 2 EXIT MEETING The inspection team met with the licensee representatives and other personnel indicated in Section 1 of this attachment on June 10, 1993. The team leader summarized the scope and findings of the inspection as presented in this report. The licensee did not identify as proprietary any of the materials provided to, or reviewed by, the inspection team during the inspection.
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