ML040650369
| ML040650369 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 04/19/2004 |
| From: | Travers W NRC/EDO |
| To: | Bell H NRC/OIG |
| Shared Package | |
| ML040650450 | List: |
| References | |
| Case No.03-02S, CR 2000-0782, G20040092, TAC MC1991 | |
| Download: ML040650369 (5) | |
Text
Contact: Edwin M. Hackett, NRR/DLPM/PDII 415-1485 April 19, 2004 MEMORANDUM TO: Hubert T. Bell Inspector General FROM:
William D. Travers
/RA Carl J. Paperiello Acting For/
Executive Director for Operations
SUBJECT:
FEBRUARY 2, 2004, OFFICE OF INSPECTOR GENERAL (OIG)
MEMORANDUM CONCERNING AGENCY RESPONSE TO OIG EVENT INQUIRY CASE NO.03-02S (NRCS OVERSIGHT OF DAVIS-BESSE BORIC ACID LEAKAGE AND CORROSION DURING THE APRIL 2000 REFUELING OUTAGE)
This memorandum responds to your memorandum to Chairman Diaz, dated February 2, 2004, concerning the Nuclear Regulatory Commission (NRC) staffs response of January 12, 2004, to OIG Event Inquiry 03-02S. The referenced OIG event inquiry was initiated in response to a Congressional request that OIG determine how the NRC staff handled Davis-Besse Condition Report (CR) 2000-0782 at the time of discovery in refueling outage (RFO) 12 (2000) and whether the CR was considered in the November 2001 decision to allow Davis-Besse to continue to operate to February 16, 2002. The NRC staffs previous response to OIG (January 12, 2004) regarding this issue provided a matrix of those recommendations from the Davis-Besse Lessons Learned Task Force (DBLLTF) report that specifically addressed the event inquiry findings and referenced the report for a complete picture of the staffs efforts. The OIG response of February 2, 2004, stated that the NRC staff had not addressed the problem of communications as an underlying cause of the findings of the OIG event inquiry and that the agency should include an expectation of improved communication between and among NRC Headquarters and regional staff and should outline specific guidance to achieve this goal. In addition, OIG specifically concluded that had the [Davis-Besse Nuclear Power Station] DBNPS inspectors been better informed of ongoing NRC industry-wide efforts to address coolant pressure boundary leakage and the effects of boric acid corrosion, they would have recognized the significance of Condition Report 2000-0782 and highlighted the information to regional management.
The DBLLTF report discusses the NRCs and industrys failure to understand the significance of boric acid corrosion of the reactor vessel head. The NRC staff believes that this failure caused the underlying communications lapses. Although the potential for this type of degradation existed previously, the significance of boric acid deposits was not understood by the staff. The assumption throughout NRC was that the boric acid deposits would be in a dry, powder-like form that could easily be removed and would not accumulate in a condition that would be corrosive to the reactor vessel head. As identified in the event inquiry, the inspectors did communicate a substantial amount of information to the region and the NRR Project Manager, particularly regarding the fouling of the containment air coolers and radiation monitor filter elements; however, the significance of this information was also not appreciated at the time.
This same failure to understand the significance of the situation was the cause of the lack of communication from Headquarters to the regions. Several elements of the matrixed DBLLTF Action Plans address this underlying issue of lack of recognition of the significance of the evidence. The desired outcome for these actions is for all NRC staff to maintain a questioning attitude and lower thresholds for communications concerning materials degradation corrosion.
More broadly, the NRC staff agrees that communications are of critical importance in all aspects of NRC activities and particularly important as an underlying cause for issues discovered at DBNPS. The corrective actions outlined in the DBLLTF Action Plans address communications beyond the topic of boric acid corrosion control. For example, corrective actions in the area of operating experience development and use are focused on enhancing communications. The recommendations to strengthen inspection guidance, institute training to reinforce a questioning attitude on the part of management and staff, and change the Inspection Manual to provide guidance for the staff to pursue issues identified during plant status reviews are intended to establish more definitive expectations for improved communications of operating experience. As discussed in the February 23, 2004, semiannual update report and at the February 26, 2004, Commission meeting, implementation plans for this area are still under development and may significantly influence the way the agency does business in the future. Developing the most effective and efficient communications channels will be key to the successful implementation of an effective operating experience program.
Beyond the DBLLTF Action Plan, the agency has several ongoing initiatives that provide examples of efforts to more broadly improve intra-agency communications. These examples include establishment of a Communication Council reporting to the Executive Director for Operations and the creation of a communications specialist position reporting to the Office of Nuclear Reactor Regulation (NRR) Associate Director for Inspections and Programs. NRR also continues to improve and enhance its Web site as a focused means of communicating with both internal and external stakeholders. From a regional perspective, examples of communication enhancements include lowering the threshold for communication of plant issues on morning status calls, devoting additional time to discussing lessons learned from plant events and inspection findings during counterpart meetings, and developing enhanced guidance for documenting significant operational event followup decisions. Collectively, these examples provide a strong indication that NRC Headquarters and regional staff have begun to internalize two of the most important lessons from the Davis-Besse event. These are that on occasion, information initially considered to have low significance by the first NRC recipient is later found to be of greater significance once the information is shared and evaluated more collegially; and with regard to the complex nature of commercial nuclear power operations, no one person can be aware of all aspects of an issue. As a result, the more information that is shared, the more likely significant problems will be identified and appropriate action(s) taken.
In summary, the NRC staff recognizes that communication failures were an underlying cause of the agencys problems concerning the delayed discovery of the boric acid corrosion at DBNPS.
Our January 12, 2004, response to the event inquiry specifically addressed what we considered to be the root cause of the event-specific communication failures, namely that the entire staff did not recognize the potential significance of boric acid corrosion. Expectations for improved communications will be developed as an integral part of our operating experience program enhancements. More broadly, communication improvement initiatives with internal and external stakeholders are in progress to enhance agency performance in this critical area of our responsibilities. We regret that our initial response did not clearly address the broader actions we are taking to improve communications and appreciate the opportunity to clarify our response.
cc: Chairman Diaz Commissioner McGaffigan Commissioner Merrifield SECY LReyes
BClayton TMarsh*
SRichards*
BBoger*
DATE 3/16/04 03/15/04 3/15/04 3/15/04 OFFICE ADIP ADPT TechEd NRR EDO NAME JCraig*
JCraig for BSheron*
PKleene*
RBorchardt for JDyer*
WTravers DATE 3/18/04 3/19/04 03/16 /04 3/19/04 04/19/04
G20040092, NRCS OVERSIGHT OF DAVIS-BESSE BORIC ACID LEAKAGE AND CORROSION DURING APRIL 2000 REFUELING OUTAGE, MEMO TO H. BELL FROM W. TRAVERS (CASE NO.03-02S)
Dated: April 19, 2004 DISTRIBUTION:
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