ML050830380

E-Mail J. Connolly, NMC, to H. Chernoff, NRR, Electronic Copy of NMC Response Team Report Due to Diver Entrapped in the Intake Structure

ML050830380
Person / Time
Site:	Point Beach
Issue date:	05/18/2004
From:	Connolly J Nuclear Management Co
To:	Chernoff H NRC/NRR/DLPM/LPD3
References
FOIA/PA-2004-0282
Download: ML050830380 (18)

Text

Harold Chernoff - FW: Electronic Copy of NMC Response Team Repor for Unit 2 Trp due to Diver Entrapped in the Intake StRe 1

,..I 2%,

From:

"Connolly, James W." <James.Connolly@nmcco.com>

To:

<hkc~nrc.gov>

Date:

Tue, May 18, 2004 1:34 PM

Subject:

FW: Electronic Copy of NMC Response Team Report for Unit 2 Trip due to Diver Entrapped in the Intake Structure at PBNP

Harold, Attached is a copy of the information related to the Diver/Reactor Trip event that recently occurred at PBNP Unit 2.

If you have any questions regarding this matter, please contact me at (920) 755-6518 Jim Connolly PBNP Regulatory Affairs Manager

- -----Original Message-----

> From:

Connolly, James.W.

> Sent:

Tuesday, May 18, 2004 11:40 AM

>To:

'pll~nrc.gov'

> Cc:

'rmm3@nrc.gov'

Subject:

Electronic Copy of NMC Response Team Report for Unit 2 Trip due to Diver Entrapped in the Intake Structure at PBNP

> Pat,

> Attached is an electronic copy of the NMC Response Team Report for Unit 2 Trip due to Diver Entrapped in the Intake Structure at PBNP that occurred on May 15th. This report is being forwarded for your information.

> If you have any questions, please do not hesitate to contact me at (920) 755-6518.

> Jim Connolly

> PBNP Regulatory Affairs Manager

> > <<NMC Intake Crib Dlving Incident Response Team.doc>>

Harold Chernoff - NIVC Intake Crib Divina Incident Resp~onse Tearn.doc Page 1 Harod Cernff NMCIntke ribDivna Icidnt es~nse eamdocPaa 1

NMC Incident Response Team For Issues Encountered During Unit 2 Trip due to Diver Trapped in Intake Structure at PBNP May 15 - 17,2004 Final Report Team Members:

Kyle Hoops (Team Lead), Kewaunee Director, Site Operations Grover Hettel, Palisades Plant Manager Randy Gunnlaugsson, Kewaunee Senior Analyst Chuck Smoker, Hudson Manager, Performance Assessment Russ Walesh, Point Beach Nuclear Oversight Performance Analyst Signed by Team Leader, Kyle Hoops 5/17/04

Harold Ch-ernoff -- NMC Intake Crib Dlving Incident Response Tearn.doc Page 2 Harold Chernoff -NMC Intake Crib Diving Incident Response Team.doc Paae2g Executive Summary On May 15, 2004 at 1154, Point Beach Unit 2 was manually scrammed from 100% power at the request of personnel at the site of a trapped diver at the intake crib. At 1155, both Unit 2 circulating pumps were stopped and the diver was rescued and out of the water within five minutes.

The diver was part of a five-person dive crew inspecting damage at the intake crib that had been identified on May 13, 2004. After approximately 90 minutes of the first dive of the day, the diver entered the inside of the intake crib in the vicinity of the operating circulating water intake bell. After about ten minutes in this area, the diver's air/communication line was sucked into the intake bell and snagged on a pipe support for a chlorine injection line. Neither the diver nor the tender on the boat were able to free the line. A rescue diver was sent into the area and was also unable to free the line. The diver ended up flattening himself on the ground against the approximate 12" lip of the operating intake bell. When the diver's communication line was lost due to fretting against the pipe support and rescue efforts to free the line had failed, the NMC construction liaison requested that the circulating water pumps be stopped. Once the pumps were stopped, the rescue diver was able to free the snagged line and both divers left the water under their own power. Neither diver required medical attention.

Through numerous interviews and document reviews, an incident response team compiled a list of issues that occurred during this event. Those issues were then characterized by failed barrier using the six Barriers for Excellence associated with the site's Picture of Excellence. The results from the barrier analysis identified the primary issues that contributed to these events. The more significant issues are listed below.

• All site departments that had a stake in the diving evolution was not involved in the job planning.

• The site views diving as a routine activity.

• It does not appear that the importance of an effective pre-job brief were recognized given the emphasis placed on the level of the briefings.

• The involved personnel did not appear to exhibit a questioning attitude.

• The site did not appear to exhibit a questioning attitude.

• The oversight by the construction liaison was inadequate during the critical time when the diver was entering the north area of the intake crib.

• Communications during the diving activity was inadequate.

• Inadequate adherence to procedures.

Harold Chernoff - NIVIC Intake Crib Dlving Incident Response Tearn.doc pi
o 6 :A3 Harold Chernoff - NMC Intake Crib Diving Incident Response Team.doc Pa Introduction On the afternoon of May 15, 2004, an Incident Response Team was requested from the NMC fleet to provide an initial investigation into issues that had occurred that morning at the Point Beach Nuclear Plant during diving activities at the site's intake structure.

The Incident Response Team began assembly and collection/review of data that day. The full team was assembled early on May 16, 2004 and the investigation continued into that evening and was concluded on May 17, 2004. The investigation included interviews of personnel involved as well as a review of station logs, statements taken immediately following the event, plant and vendor procedures, the work package for the dive, action requests, operating experience evaluations, federal safety requirements, past PBNP events, and similar industry events.

A barrier analysis approach, using the six Barriers for Excellence associated with the site's Picture of Excellence and ACEMAN for Individual Excellence, was used to identify all of the individual issues that occurred and associated barriers that failed. From analysis of the failed barriers, the team and site were able to evaluate appropriate actions to implement to prevent similar events as the one that initiated this investigation. In addition, analysis of the failed barriers also facilitated determination of the common underlying issues that contributed to the failure of the multiple barriers. In an effort to retain the focus of the incident response team, action requests were generated for items that require further evaluation outside of the charter of the team.

Incident Response Team Charter

1. Determine the process, procedures, and organizational failures that enabled a diver to become dangerously close to serious injury or death.

2. Recommend the immediate actions required to implement barriers that would prevent such an event.

3. Create a time line of the event.

Background & Description of Events On May 13, 2004, a dive was planned to complete installation of the fish deterrent speaker system. The first three speakers of this system were installed April 27"' but the remainder could not be installed at that time due to rough weather. The dive on May 13"'

was also intended to include the annual inspection of the intake crib and its grating.

The intake crib is approximately 110 feet in diameter. It consists of an outer ring with a radius of 25 feet that is filled with 3 to 12 ton blocks of limestone. Inside this outer wall is the actual intake area, a cylinder about 7 feet tall with a 60-foot diameter. A trash rack that consists of a north and south semicircle covers this intake area. Each semicircle is 3

Harold Chernoff - NMC Intake Crib Dlving !Icident Respnse eam.doc P

.4 supported independently by 18 I-beams along its outer edge and 5 I-beams down the middle of the intake area. On the floor of the intake structure, there are two 18-foot diameter intake bells, one on each the north and south sides. These intake bells are raised approximately 12' above the floor of the structure.

For the dive on May 13, 2004, the dive crew was briefed via telecom by the construction liaison. The construction liaison did not go with the dive crew on this dive. During the dive, the remainder of the speakers were installed and an inspection of the intake structure was completed. The intake inspection discovered several items that were damaged with some lying on the bottom of the structure. During this dive, the diver went inside the intake structure for about five minutes to inspect the damage more closely. Upon completion of the dive, the dive crew notified the construction liaison of the damage that had been observed.

On May 14, 2004, the construction liaison went to the Outage Control Center to discuss the damage that was observed with the Shift Outage Manager. The Shift Outage Manager arranged for a meeting between the construction liaison, the system engineer, and the system engineer's supervisor. This subsequent meeting focused on the amount of damage and its impact on the plant. The discussion centered around current operability and reliability as well as what further information was necessary. During this discussion, the dive on May 15, 2004 was discussed. Everyone agreed it was important to conclude that dive, as a detailed intake inspection was required to understand repair options as well as impact on the units. This discussion did not cover the fact that the dive would have to include time under the intake structure. The system engineer believed that time under the intake structure was required based on what information was needed; however, this was not explicitly discussed.

Later that day, the construction liaison discussed the description of the damage with the Shift Manager. This discussion also focused on the extent of the damage and did not include a dialogue on the next day's dive and its possible impact on the operating unit.

Over the course of the day, the Work Control Center SRO was also notified of the damage and the fact that a dive would occur the next day, May 15, 2004.

On May 15, 2004, Seaview Diving Contractors brought two boats with a total of five divers. One of the boats picked up the construction liaison at the PBNP intake structure.

Both boats then proceeded out to the intake structure. When above the intake structure, a pre-job brief was conducted by the construction liaison. Since he had completed the high risk pre-job briefing formn when the diving first started in April, this pre-job briefing was performed without using any specific checklist. The briefing covered the specific scope of the dives planned for the day as well as emphasis on the need for special attention to personnel safety as the stability of the intake structure was not conclusively known.

Based on interviews with the construction liaison and the divers, an important portion of the pre-job briefing was not clear. The construction liaison believes that his briefing covered an external and internal inspection of the south side of the intake structure, which had no flow. The construction liaison then described inspecting only the exterior of the 4

Harold Chernoff - NMC Intake Crib Diving Incdent Response Team.doc Page 5 north side of the intake structure because there was circulating water flow through the north intake bell. What the divers heard during the pre-job brief was that they were to inspect the exterior of the north and south sides and the interior of the south side.

However, they understood that they had the option of inspecting the north side if needed.

Following the pre-job brief, the construction liaison contacted the Work Control Center SRO who then informed the control room that the diver was entering the water at the intake structure. The diver entered the water at 1004 and began his inspection on the south side. The diver entered the south side of the intake structure on at least three different occasions. When inside the south side and inspecting the total of ten I-beams down the centerline of the intake structure, the diver was within a couple of feet of the operating north intake bell. He did not notice any flow at that time.

At 1120, the diver begins to inspect the north side from the outside of the structure. He quickly determines that he is unable to see the top of the I-beams on the circumference of the north side because the rock wall extends up too high. At 1125, the diver notifies the boat that he can't see the top anchors on the north and will be entering the north side.

The dive team member that was monitoring the video paused, waiting for a comment or reaction from the construction liaison. When the construction liaison did not make any comment or physical motion, the dive team member assumed that entering the north half was acceptable and he acknowledged to the diver that it was understood that the diver was entering the north half of the structure. At about the time of this discussion between the boat and the diver, the construction liaison received a call from engineering to discuss a message he had left earlier in the dive about the damage that had been observed at this point in the dive. It is believed that the construction liaison was on the phone or otherwise distracted when the diver entered the north side, as the construction liaison does not remember hearing any conversation between the boat and the diver about entering the north side.

At 1132, the videotape shows the air/communication line being drawn into the north intake pipe and then pulled by the diver out of the pipe. At 1135:12, the diver was seen pulling the tether out of the intake bell. The tether was almost immediately drawn back into the intake pipe at 1132:22. The diver continued on with his inspection, apparently not realizing that his tether was drawn back into the intake piping. At 1136:47, it appears the diver recognized that his lines are snagged inside the intake bell. The videotape was stopped at 1137 as the dive team focused on the diver in distress. The diver worked to free his lines but as he did, he lost his footing. He dropped to his belly and slid on the floor of the intake structure toward the intake bell. He stayed under the 12" lip of the intake bell so he would not be drawn into the pipe. As this was occurring, a rescue diver was dressed out and then sent into the water. The rescue diver was dressed in a dive helmet with a tether, air, and communication line. The rescue diver went under the structure and down near the intake bell but was unable to free the snagged line. The line was seen snagged on a pipe support for a chlorine injection line. The rescue diver then proceeded to the outside of the intake structure and went on top of the trash rack so that he could observe the diver from a safer position.

5

Harold Chernoff - NMC Intake Crib Dlving Incident Response Team.doc Page 61 Harold Chernoff - NMC Intake Crib DIvinj Incident Response Team.doc Paae6 

The dive team briefly discussed taking a new tether down to the diver, tying him off, and then cutting the snagged lines. However, at about this time, communication with the diver was lost due to fretting of the communication line inside the intake bell. The team then immediately decided that flow was required to be stopped. The construction liaison contacted the Work Control Center and asked that the plant be shut down and circulating water pumps be stopped. Unit 2 was manually scrammed at 1154 and both circulating water pumps were stopped at 1155. With flow secured, the rescue diver was able to enter the intake structure and free the first diver. Both divers then returned to the boat. No medical attention was necessary.

Event Significance & Implications:

The decision-making and operational focus that allowed the diver to enter the north area of the intake crib is of great concern and significance to Point Beach Nuclear Plant and to NMC.

The intake crib diving event is a matter of industrial safety, for which a diver was placed in grave danger, and nuclear safety, for which the plant was challenged by a manual trip of the reactor. The decision-making, communication and supervisor oversight are underlying cultural issues that have been exhibited by other events at the site. This prevents Point Beach from meeting the Picture of Excellence in being Predictable and will also bring into question the sites credibility with the regulator.

The actual nuclear and industrial safety significance of the event will be explored further in the root cause evaluation for the Intake Crib Inspection event to be performed by the site.

Analysis Against The Barriers For Excellence:

Relative to the discussion of the six Barriers For Excellence, the barriers will be discussed as to whether the Barrier was adequate, degraded or failed. From the tables, common underlying themes have been identified.

6

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Harold Chernoff -NMC IntakeCrib DIvinginckient ResponseTea1.doc Page 811 w_

mad, Qualified Workers (Degraded) 1

.indings Assessment of Fndings Knowledge of Work

• Interviews with the five Divers indicated that they believed the scope of work at It was clear that not all personnel Scope the intake crib included inspection from the outside of the crib and inspection of involved with the diving operation inside the crib on the south side and could inspect inside the crib on the north side understood the scope of work during the if needed. Interview with the Construction Liaison indicated that he believed the intake crib work. There is not clear scope of work at the intake crib included inspection from the outside of the crib discussion or write-up of the scope of and inspection of the south portion of inside the crib but not the north portion.

work to be done at the intake crib. The

• Interview with the system engineer for the intake crib indicated that he believed work order description of the intake crib the scope of work at the intake crib included inspection from the outside of the is very general and does not discuss crib and inspection both on the north and south portions of inside the crib. This whether inspections are to be performed was based on assumptions he made based on discussions he and the construction inside or outside the intake crib or liaison had on Friday, May 14'.

precautions to be taken.

• Interview with the Work Control Center SRO indicated that he was not aware of the full scope of the diving inspection at the intake crib other than the divers were doing an inspection. Assumed it was a routine dive.

• Discussion with the Shift Outage Manager indicated that he was not aware of the scope of the diving at the intake structure. He was only aware that damage was found during work on Thursday and was helping the Construction liaison get the Engineering help he needed.

Divers Qualifications

• All divers had the appropriate qualifications required for the diving activity.

• There is no formal qualification for Contractor Liaisons. The construction engineer that was the liaison for this diving activity last completed the contractor liaison training in 1990.

Harold Chernoff - NMC Intake Crib Diving Incident Response Team.doc Paae 9 1 s

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Job Planning/Preparation (Failed) u es

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Pre-dive Preparations Interviews indicated that there was confusion between the divers and the All site departments that had a stake in construction liaison on how the inspection of the crib was to be conducted. The the diving evolution was not involved in divers believed that they were to inspect inside the crib on the south side and the job planning. The level of could inspect inside the crib on the north side if needed. The construction liaison involvement by Operations, Safety and believed that the inspection inside the crib was only to be conducted on the south Engineering contributed to the area.

consequences of the diver being trapped

• The work order was not revised to reflect the change in scope of the inspection.

and the Unit being manually tripped.

The work instruction was written so broadly that the construction liaison did not believe that the work order needed to be revised.

• The change in scope of work was discussed with engineering.

• The change in scope of work was discussed with a shift manager in operations.

• The change in scope of work was not discussed with Safety.

• It was determined that the construction liaison would contact the Work Control Center verses contacting the Control Room. This is contrary to the Intake Crib Inspection procedure.

• The first note in Section 5.0 of procedure RMP 9155-5 requires a special evaluation by engineering and operations if diving is to be conducted inside the intake crib. Diving inside the intake crib on Thursday, May 13' occurred without a special evaluation. A meeting on Friday, May 14', was conducted with engineering. A separate discussion with a shift manager was conducted also on Friday. The construction liaison considered these two evolutions as the special evaluation for the diving inside the intake crib on Saturday, May 15'.

Site sensitivity to Diving

• The diving evolution was not discussed at the POD.

Site views diving operations as

• Diving appears to be considered a routine evolution.

routine.

• It was stated by some during the interviews that "Diving is Inherently Dangerous".

• Discussion between the construction liaison and engineeringloperations was centered around the damage and repairs of the intake crib and did not include I

discusion of the safety snd risk of the diving ope1'tion

I I Harold Chernoff - NMC Intake Crib DIving Incident Response Team.doc Page 10 -1 i

I Diving Pre-Job Brief

• Communications during the pre-job brief were not clear and direct concerning areas in the intake crib that were not allowed to be entered by the divers.

• Interviews with the five divers and the construction liaison indicated that the pre-job brief was not effective in ensuring that all involved had the same understanding of the full scope of the inspection.

• Pre-job brief on Work Order 0306041 "Intake Crib Inspection per RMP 9155-5" was performed using PBF-9205 "High Risk Work Pre-Job Briefing Checklist".

The initial pre-job brief was conducted in April 2004. All subsequent pre-job briefings for diving performed under this work order at later dates included only scope, hazards and safety. Operating Experience was only discussed on initial pre-job brief. This does not meet the intent of RMP 9155-5 section 23.1.

• Intake Crib Inspection Procedure Attachment A "Diving Pre-Job Brief Checklist" was not signed off indicating completion of form.

• Expected flow velocities and profiles inside the intake crib were not discussed during the pre-job brief.

• Pre-Job Brief for the intake crib diving on Saturday, May 15t. was conducted on the boat at the intake crib. The only individuals present for the brief were the five divers and the construction liaison.

• The initial pre-job brief conducted in April 2004 did not include all the divers involved in the intake crib diving on Saturday. May 15`.

Pre-job brief did not emphasize the restricted areas within the intake crib.

• It does not appear that the importance of an effective pre-job brief was recognized given the emphasis placed on the level of the briefings.

Effective pre-job briefings cannot be conducted without having full representation of involved site personnel. There were no engineering, safety or operations personnel at briefings.

10

Harold Chernoff - NMC Intake Cib DIving Incident Response Tean.doc Page 11 ll Procedures/Work Instructions (Degraded)

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Assessment of Findings f

Intake Crib Inspection

• Intake Crib Inspection is very generic in the details of how to perform the Due to its general nature, the RMP 9155-5 inspections of the intake crib. It does not discuss whether the inspections should be procedure is inadequate as a barrier to conducted inside or outside the crib.

nuclear and personnel safety.

• Attachment A of the procedure does not include any item that requires discussion of restricted/prohibited areas.

• The procedure does not provide any guidance on expected flows or how to align Circulating Water Pumps to aide in minimizing flow.

• The procedure does not provide any guidance on who should attend the pre-job briefs for diving. During interviews it appeared that the individual most knowledgeable about flow rates in the crib during circulating water pump operations was the system engineer. He stated that he had not attended a diving pre-job brief in many years.

• The special evaluation mentioned in Section 5.0 in not clearly defined. This allows the evaluation to be conducted very casually.

• Procedure does not have adequate roles and responsibilities for engineering and operations in regards to diver safety and plant safety during diving operations.

• The evaluation of SEN-245 "Near Fatal Diving Incident in Circulating Water Discharge Vault" appears to be narrowly focused on work in the fore-bays and not the entire circulating water intake system.

Diving Contractor

• The Activity Hazard Analysis form was not provided to the site for the diving Dive Plan operations on Saturday.

Harold Chernoff - NMC Intake Crib Dlying Incident Response Team.doc

Page12 d At Verification/Validation (Failed)

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Decision making Neither the Outage Control Center, the Work Control Center, nor the on-shift Those involved did not recognize the Operating Crew were involved with the decision-making. This reduced the potential significance of the decision opportunity to identify risks or ways to reduce the risks.

being made.

• Operations and Engineering were only informally involved in the decision-making

• Additional verification/validation when making the decision to perform diving inside the intake crib, from knowledgeable Operational

• During the decision, focus was on what was required to ensure the intake crib was personnel was not obtained. This intact and repaired and not on the risk placed on the divers and the operating unit.

could have lead to recognition of the risk associated with the flows in the intake crib and the ability to reduce the flows.

Lack of questioning

• Although the divers and the construction liaison understood that the intake crib

• The involved staff did not appear to attitude would have increased flows around the north inlet pipe, they did not question the exhibit a questioning attitude. The ability of operations to decrease the flow in the intake crib.

diving crew had signs of high flows

• When the diver prepared to enter the north area of the intake crib, the diver and the exhibited by the tether being drawn dive team member watching the video monitor paused for concurrence from the into the intake pipe.

construction liaison. When nothing was received from the liaison, the dive team member took the silence as concurrence.

The site did not appear to exhibit a

• The diver saw the tether being drawn into the intake line two separate times prior to questioning attitude. Although the getting caught in the intake pipe. This was captured on the video and was not diving activity was on the work questioned by any of the other members of the diving team.

schedule and Operations and Inadequate or imprecise communications were noted during the pre-job briefing on Engineering were involved in the Saturday, May 15'. The divers believed that they were to inspect inside the crib on initial discussion of the diving the south side and could inspect inside the crib on the north side if needed. The activity on Saturday, opportunities construction liaison believed that the inspection inside the crib was only to be were missed to identify and mitigate conducted on the south area.

the risks involved for personnel and Lack of questioning attitude by the Shift Outage Manager. When the construction nuclear safety.

liaison came to the Shift Outage Manager requesting help to get engineering involved with the inspection results, he did not consider getting the operations personnel on the operating unit involved.

• Operations did not adequately question the scope of the diving activities at the intake crib prior to allowing work to commence.

Harold Chernoff - NMC Intake Crib DIving Incident Response Team.doc Page 13K-i Supervisor Oversight (Failed)

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Intake Crib Inspection procedure requires the construction liaison to '...monitor

• The oversight by the construction Responsibilities dive work continuously when divers are in the water...". The construction liaison liaison was inadequate during the was distracted by a phone conversation with an engineer during the period that the critical time when the diver was diver entered the north area and became entangled.

entering the north area of the intake

• During the diving activities on Thursday, May 13'. the construction liaison was not crib. If the liaison would have been present on the boat.

watching the dive on the monitor, he

• Operations and the construction liaison did not establish communications as could have stopped the diver once he described by the Intake Crib Inspection procedure. Instead the liaison diver approached the north area in the communicated with the Work Control Center SRO.

intake crib.

• The diving supervisor was the diver used to inspect the intake crib.

Expectations

• Expectations are not clear on who should be present for a diving pre-job briefing.

• The pre-job briefings for nany of the diving evolutions are held on the boat just prior to diving.

• Operations involvement with the diving evolution was not adequate. Operations believed that the diving was a routine evolution.

I Harold Chernoff - NMC Intake Crib Diving Incident Response Team.doc Page 1411 I

Worker Practices (Failed) issues.

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55 et o di s Communications

• Communications between the divers and the construction liaison were not

• Communications during the diving adequate during the critical period when the diver approached the north area activity was inadequate in preventing of the intake crib.

the diver from entering a hazardous

• Communications between the engineer and the construction liaison were not area.

adequate when discussing the method of inspecting all portions of the intake crib to determine extent of condition. The engineer assumed the construction liaison understood that diving would have to be conducted in and around the north intake pipe.

Procedure Use

• Attachment A 'Diving Pre-Job Brief Checklist" of the Intake Crib Inspection Inadequate adherence to procedures procedure was not completed prior to each dive.

weakened the worker practice barrier

• A special evaluation with engineering and operations personnel is required to be conducted any time that diving is to be conducted inside the intake crib. This was performed very informally.

• The construction liaison was not present on the boat during the diving activities conducted on Thursday. This is contrary to the requirements in the Intake Crib Inspection procedure.

• Operations and the construction liaison did not establish communications as described by the Intake Crib Inspection procedure. Instead the liaison communicated with the Work Control Center SRO.

I Harold Chernoff - NMC Intake Crib DIvina Incident Resr)onse Team.doc Piaage-1.5 I Harold Chernoff - NMC Intake Crib DIvinG Incident Response Team.doc Paaei5g

==

Conclusion:==

To summarize the results from the barrier analysis, the primary issues that contributed to this event are listed below.

• All site departments that had a stake in the diving evolution were not involved in the job planning. The level of involvement by Operations, Safety and Engineering contributed to the consequences of the diver being trapped and the Unit being manually tripped.

• The site views diving as a routine activity. This could possibly be specific to diving or could be a broader Operational Focus issue.

• It does not appear that the importance of an effective pre-job brief was recognized given the emphasis placed on the level of the briefings. The pre-job brief did not emphasize the restricted areas within the intake crib. The pre-job brief was conducted without having full representation of appropriate site personnel. There were no engineering, safety or operations personnel at briefings.

• The involved personnel did not appear to exhibit a questioning attitude. The diving crew had signs of high flows exhibited by the tether being drawn into the intake pipe.

• The site did not appear to exhibit a questioning attitude. Although the diving activity was on the work schedule and Operations and Engineering were involved in the initial discussion of the diving activity on Saturday, opportunities were missed to identify and mitigate the risks involved for personnel and nuclear safety.

• The oversight by the construction liaison was inadequate during the critical time when the diver was entering the north area of the intake crib. If the liaison would have been watching the dive on the monitor, he could have stopped the diver once he diver approached the north area in the intake crib.

• Communications during the diving activity was inadequate in ensuring that the diving crew knew that entering the north intake structure area was prohibited.

• Inadequate adherence to procedures weakened the worker practice barrier.

• The Intake Crib Inspection procedure is inadequate as a barrier to nuclear and personnel safety.

• Safety Department was not involved in any portions of the diving activities.

This summary indicates that some of the principles provided in INPO's Principles for Effective Operational Decision-Making were not present during this event. Those applicable are listed below.

• Potential consequences of operational challenges are clearly defined, and alternative solutions are rigorously evaluated.

• Lack of questioning attitude, advocacy of questions and self critical nature, The lack of a rigorous evaluation of the intake crib inspection activity prevented the identification of potential consequences of operational challenges being clearly defined in the work order or procedure. This failure allows both personnel safety and nuclear safety being challenged.

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-- I--

I Harold Chernoff - NIVIC Intake Crib DIvinq Incident Response Team.doc -

-Pag6e~ 1-6 Haol Chnf _ NC InaeCi liqIcdn epneTawo ae11 Day Time What occurred 5/13/2004 Installation of fish barrier. Saw damage to intake structure.

Went inside the structure for about 5 minutes. Was at least 10 feet from the intake.

5/14/2004 About Liaison discusses damage to intake structure with SOM in 1000 OCC About Special evaluation discussing entry into north side with Zipp, 1030 Crowley, Grasso 5/15/2004 AM Pre-job brief on the boat 1004 Diver enters water 1007 From unofficial Ops log - "Construction Engineering notified control that divers are commencing work at the intake structure. Expect work to continue through 5 PM. (Misc. Tom Jessessky from WCC" 1017 Begins to enter south side of structure 1021 Inside the structure 1025 On top of the structure 1048:30 Directed "to go underneath to look at #2 bolting 1048:50 Pulling up on the cable (take up the slack)(may have been snagged) 1050:38 Went underneath on south side 1059 Microphone was cutting out, 5 seconds later it was OK 1100 Communications told him to be careful 1101 At edge of Unit 1 intake bell, the chlorination piping is visible.

1118 Heading west out from the structure 1119 Tether appears to be hung up on the rocks on two occasions.

Appeared to be easily freed 1120 Out and descending on to the north side 1125 Reminded to be careful of pinch points 1125:49 Inside the rocks, above the trash racks, Can't see what he wants to see, Notifies over communication that he wants to go inside. Goes back down under the trash racks 1132:14 Radio conversation "taking a strain" Air/Communication line seen in the intake pipe.

1132:40 Air/Communication line pulled from the intake pipe About Grasso receives call from Zipp 1135 1135:12 Tether was seen being pulled out of the pipe 1135:22 Tether drawn right back in the intake. Diver continues to l_

work.

1136:37 Both the tether and air/communication line are in the pipe 1136:46 Radio communication "Need to back out now" 1136:55 Radio communication "Taking a strain"

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PBNP Intake Crib Inspection Event Timeline May 13 -15,2004 About Rescue diver dons diving suit. Enters water. Gets within a 1137 few feet from the intake. Feels "unsafe amount of suction".

Tried to free the umbilical. Communication lost with diver.

Communications told him to standby 1137:13 Video ends About WCC receives call and informed of a diver emergency at the 1150 intake crib. WCC put on hold. Shift Manager summoned from his office to the Control room. About 1 minute later, Grasso requests a trip.

1154 From unofficial Ops log - "Control room received report that a diver is stuck at the intake crib. Rescue diver cannot retrieve diver. Unit 2 manually tripped."

1155 From unofficial Ops log - Unit 2 Circulating Water pumps shutdown.

1157 From unofficial Ops log - Diver reported still trapped. Rescue diver has re-entered the water."

1159 From unofficial Ops log - Received report that the rescue diver has successfully retrieved the stuck diver. Both have exited the water.

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