Information Notice 1989-72, Failure of Licensed Senior Operators to Classify Emergency Events Properly
UNITED STATES
NUCLEAR REGULATORY COMMISSION
-OFFICE OF NUCLEAR REACTOR REGULATION
WASHINGTON, D.C.
20555
October 24, 1989
NRC INFORMATION NOTICE NO. 89-72: FAILURE OF LICENSED SENIOR OPERATORS TO
CLASSIFY EMERGENCY EVENTS PROPERLY
Addressees
All holders of operating licenses or construction permits for nuclear power
reactors and all licensed operators of nuclear power reactors.
Purpose
The purpose of this notice is to alert addressees to potential problems related
to failures of licensed control room senior operators to classify events pro- perly using the site-specific emergency plan implementing procedures.
It is
expected that recipients will review the information for applicability to their
facilities and consider actions, as appropriate, to avoid similar problems.
Suggestions contained in this information notice do not constitute NRC require- ments; therefore, no specific action or written response is required.
Description of Circumstances
The NRC has identified inaccurate emergency action level classifications during
operator examinations and during emergency exercises. NRC requalification
examinations, conducted earlier this year with typical operating shift crews, identified at several plants the failure of licensed senior operators to pro- perly classify events on the basis of plant conditions presented on the control
room simulator.
Also, several events were improperly classified, based on simu- lated plant conditions, during the course of NRC requalification examinations
or evaluations of emergency exercises.
Recently, one nuclear power station was
issued a civil penalty because shift supervisors did not know how to classify
emergency events properly.
Such classification problems have also occurred during actual events.
At one
facility, in January 1989, an Alert was not declared (as it should have been)
during a reactor coolant system leakage situation that occurred while the
reactor was in a cold shutdown condition.
Discussion:
It is essential.that operators be able to recognize degraded plant conditions, classify the emergency on the basis of those conditions, and activate emergency
response capabilities of the utility and offsite organizations at the appropri- ate emergency action level. Demonstrating knowledge of the emergency plan,
910800 2Z
<-ON 89-72 October 24, 1989 including the responsibility to decide whether the plan should be executed, is
required by 10 CFR 55.45, "Operating Tests." Requalification examinations and
emergency exercises have been administered by the NRC under the shift team format
at numerous facilities at which licensed senior operators were required to demon- strate this competence.
At several facilities there has been lack of emphasis, during operator requali- fication training, on the bases of and strategies for the implementation of the
This weakness has led to the problems noted above.
The NRC has
noted a direct correlation between inadequate training and incorrect performance
by licensed operators. At facilities where licensed senior operators satisfac- torily passed the requalification examination, the training program included
intensive simulator training on event classification as opposed to relying
solely on classroom exercises and lectures.
The root causes for classification errors are attributable to implementing
procedures that are not "user friendly" and to ineffective training methods.
Implementing procedures are sometimes difficult to interpret and, in some
cases, it was apparent that licensed operators had not received sufficient
training in event classification to understand and implement the guidance
provided. It is important that licensees ensure the usability of event clas- sification procedures and the effectiveness of training in those procedures.
This information notice requires no specific action or written response.
If
you have any questions about the information in this notice, please contact
the technical contact listed below or the appropriate NRR project-manager..
Charles E. Rosi, Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical Contact:
C. Casto, Region II
(404) 331-5594 Attachment:
List of Recently Issued NRC Information Notices
- 1 X
i
Yttachment
IN 89-72 October 24, 1989
- -
LIST OF RECENTLY ISSUED
NRC INFORMATION NOTICES
Information
Date of
Notice No.
Subject
Issuance
Issued to
89-71
89-70
89-69
89-68
Diversion of the Residual
Heat Removal Pump Seal
Cooling Water Flow During
Recirculation Operation
Following a Loss-of-
Coolant Accident
Possible Indications of
Misrepresented Vendor
Products
Loss of Thermal Margin
Caused by Channel Box
Bow
Evaluation of Instrument
Setpoints During
Modifications
10/19/89
10/11/89
9/29/89
9/25/89
All holders of OLs
or CPs for nuclear
power reactors.
All holders of OLs
or CPs for nuclear
power reactors.
All holders of OLs
or CPs for BWRS.
All holders of OLs
or CPs for nuclear
power reactors.
-- 89-67
Loss of Residual fleat
Removal Caused by
Accumulator Nitrogen
Injection
9/13/89 All holders of-OLs
89-66
88-46, Supp. 4
89-65
89-64
Qualification Life of
Licensee Report of
Defective Refurbished
Circuit Breakers
Potential for Stress
Corrosion Cracking in
Steam Generator Tube
Plugs Supplied by
Babcock and Wilcox
Electrical Bus Bar Failures
9/11/89
9/11/89
9/8/89
9/7/89
All holders of OLs
or CPs for nuclear
power reactors.
All holders of OLs
or CPs for nuclear
power reactors.
All holders of OLs
All holders of OLs
or CPs for nuclear
power reactors.
OL = Operating License
CP = Construction Permit
I
IN 89-72 October 24, 1989 including the responsibility to decide whether the plan should be executed, is
required by 10 CFR 55.45, "Operating Tests." Requalification examinations and
emergency exercises have been administered by the NRC under the shift team format
at numerous facilities at which licensed senior operators were required to demon- strate this competence.
At several facilities there has been lack of emphasis, during operator requali- fication training, on the bases of and strategies for the implementation of the
emergency plan. This weakness has led to the problems noted above. The NRC has
noted a direct correlation between inadequate training and incorrect performance
by licensed operators.
At facilities where licensed senior operators satisfac- torily passed the requalification examination, the training program included
intensive simulator training on event classification as opposed to relying
solely on classroom exercises and lectures.
The root causes for classification errors are attributable to implementing
procedures that are not "user friendly" and to ineffective training methods.
Implementing procedures are sometimes difficult to interpret and, in some
cases, it was apparent that licensed operators had not received sufficient
training in event classification to understand and implement the guidance
provided. It is important that licensees ensure the usability of event clas- sification procedures and the effectiveness of training in those procedures.
This information notice requires no specific action or written response. If
you have any questions about the information in this notice, please contact
the technical contact listed below or the appropriate NRR project manager.
Charles E. Rossi, Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical Contact:
C. Casto, Region II
(404) 331-5594 Attachment: List of Recently Issued NRC Information Notices
- SEE PREVIOUS CONCURRENCES
EAB:NRR
EAB:NRR
TECH:EDITOR
RII:DRIS
C:EAB:NRR
- RBenedict:db *RLobel
- RSanders
- KPerkins CJHaughney
9/28/89
10/3/89
9/28/89
10/4/89
10/16/89
- C:OGCB:NRR
C:LOLB:NRR C:PEPB:NRR C:IRB:AEOD
DD:AEOD
CHBerlinger *GWright
- RErickson *DCollins
- CHeltemes
10/17/89
10/4/89
10/4/89
10/10/89
10/10/89
1O/g/89
. i
IN 89 October , 1989 Demonstrating knowledge of the emergency plan. including the licensed senior
operator's responsibility to decide whether and how the plan shall be executed.
is required by 10 CFR 55.45, "Operating Tests." Requalification examinations
and emergency exercises have been administered by the NRC under the shift team
format at numerous facilities at which licensed senior operators were required
to demonstrate this competence.
At several facilities there has been lack of emphasis, during operator re- qualification training. on the bases of and strategies for the implementation
of the emergency plan. This weakness has led to the problems noted above. The
NRC has noted a direct correlation between inadequate training and incorrect
performance by licensed operators. At facilities where licensed senior operators
satisfactorily passed the requalification examination, the training program
included intensive simulator training on event classification as opposed to
relying solely on classroom exercises and lectures.
The root causes for classification errors are attributable to implementing
procedures that are not *user friendly" and to ineffective training methods.
Implementing procedures are sometimes difficult to interpret and, in some cases, it was apparent that licensed operators had not received sufficient training
in event classification to understand and implement the guidance provided. It
is important that licensees ensure the usability of event classification
procedures and the effectiveness of training in those procedures.
No specific action or written response is required by this information
notice. If you have any questions about this matter, please contact the
technical contact listed below or the Regional Administrator of the
appropriate regional office.
Charles E. Rossi, Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical Contact:
Mr. C. Casto
(404) 331-5594 Attachment: List of Recently Issued NRC Information Notices
- SEE PREVIOUS CONCURRENCES
EAB:NRR
EAB:NRR
TECH:EDITOR
RII:DRIS
C:EAB:
- RBenedict:db *RLobel
- RSanders
- KPerkins CJHaughney
/
/89
/ /89
/
/89
/ /89
/Q / /89 C:0(00
C:LOLB:NRR C:PEPB:NRR C:IRB:AEOD
DD:AEOD
D:DOEA:NRR
CHBerlinger *GWright
- RErickson *DCollins
- CHeltemes CERossi
fD/I7/89
/ /89
/
/89
/ /89
/
/89
/ /89
IN 89 October . 1989 Demonstrating knowledge of the emergency plan. including the licensed senior
operator's responsibility to decide whether and how the plan shall be executed, is required by 10 CFR 55.45, Operating Tests." Requallfication examinations
and emergency exercises have been administered by the NRC under the shift team
format at numerous facilities at which licensed senior operators were required
to demonstrate this competence.
At several facilities there has been lack of emphasis, during operator re- qualification training, on the bases of and strategies for the implementation
of the emergency plan. This has led to the problems noted above. The NRC has
noted a direct correlation between inadequate training and incorrect performance
by licensed operators. At facilities where licensed senior operators satis- factorily passed the requalification examination, the training program included
intensive simulator training on event classification as opposed to relying
solely on classroom exercises and lectures.
The root causes for classification errors are attributable to implementing
procedures that are not 'user friendly" and to ineffective training methods.
Implementing procedures are sometimes difficult to interpret and, in some cases, it was apparent that licensed operators had not received sufficient training
in event classification to understand and implement the guidance provided. It
is important that licensees ensure the usability of event classification
procedures and the effectiveness of training in those procedures.
No specific action or written response is required by this information
notice. If you have any questions about this matter, please contact the
technical contact listed below or the Regional Administrator of the
appropriate regional office.
Charles E. Rossi. Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical Contact:
Mr. C. Casto
(404) 331-5594 Attachment: List of Recently Issued NRC Information Notices
- SEE PREVIOUS CONCURRENCE
EAB:NRR
EAB:NRR
TECH:EDITOR
RII:DRIS
C:EAB:NRR
- RBenedict:db *RLobel
- RSanders
- KPerkins CJMaughney
/
/89
/ /89
/ /89
/ /89
/ /89 C:OGCB:NRR
C:LOLB:NRR C:PEPB:NRR C:IRB:AEOD
DD:AEOD
D:DOEA:NRR
CMBerlinger G6right
- RErickson DCollins
CHeltemes CERossi
/
/89 l/i/y9
/
/89 to/il /89
- /1/89
/
/89 Ilt
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IN 89
October , 1989
Page 2 of
senior operators were required to demonstrate this competence.
At several sites there has been an apparent lack of emphasis during operator
requalification training on the bases of and strategies for the implementation
of the emergency plan. This has led to misclassification of events during
operator training. operator license examinations, and emergency exercises, as
well as during actual events. There is an apparent direct correlation between
inadequate training and incorrect performance by licensed operators. At sites
where licensed senior operators satisfactorily passed the requalification exami- nation, the training program included intensive simulator training on event
classification as opposed to relying solely on classroom exercises and lectures.
The root causes for classification errors are apparently attributable to
implementing procedures that are not "user friendly" and ineffective training
methods. Implementing procedures are sometimes difficult to interpret and, in
some cases, it was apparent that licensed operators had not received sufficient
training in event classification to understand and implement the guidance
provided. It is important that licensees ensure the usability of event
classification procedures and the effectiveness of licensed operator training
in those procedures.
No specific action or written response is required by this information
notice. If you have any questions about this matter, please contact the
technical contact listed below or the Regional Administrator of the
appropriate regional office.
Charles E. Rossi, Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical Contact:
Mr. C. Casto
(404),$1W-5594 r1es
Attachment: List of Recently Issued NRC Information Notices
DOCUMENT NAME:
FOR BENNETT
- (see previous concurrence)
- EAB:NRR
EAB:NRR
- TECH:EDITOR
RBenedict:db RPobel
09/28/89 L( /3/89
09/28/89 II:DRS
C:EAB:tNPR
KPerkins
CJHaughney
/0 /4(/89
/ /89 C:OGCB:NRR
CHBerlinger
/ /89 C:LOLB:NRR
GWright
/ /89 C:PEPB:NRR
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Ifo/ A118%
Int
C:IRB;AEOD
DCollins
/ /89 DD:AEOD
CHeltemes
/ /89 D:DOEA:NRR
CERossi
/ /89
IN 89
October , 1989
Page 2 of
senior operators were required to demonstrate this competence.
At several sites there has been an apparent lack of emphasis, during operator
requalification training, on the bases of and strategies for the implementation
of the Emergency Plan.
This has led to misclassification of events during
operator training, operator license examinations, and emergency exercises, and
during actual events. There is an apparent direct correlation between inadequate
training and incorrect performance by licensed operators. At sites where
licensed senior operators satisfactorily passed the requalification examination
the training program included intensive simulator training on event classification
as opposed to relying solely on table-top exercises and classroom lectures.
The root causes for classification errors are apparently attributable to non- user friendly' implementing procedures and ineffective training methods.
Implementing procedures are sometimes difficult to interpret and. in some
cases, it was apparent that licensed operators had not received sufficient
training in event classification to understand and implement the guidance
provided. It is important that licensees assure the usability of event
classification procedures and the effectiveness of licensed operator training
in those procedures.
No specific action or written response is required by this information
notice. If you have any questions about this matter, please contact the
technical contact listed below or the Regional Administrator of the
appropriate regional office.
Charles E. Rossi, Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical Contact:
Mr. C. Casto
(404) 841-5594 Attachment: List of Recently Issued NRC Information Notices
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