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Category:- No Document Type Applies
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2020-09-02
[Table view] |
Text
L.4J UNIT 1 2 3 NIGHT ORDER Page 1 DATE: July 1, 2004 TIME: 0710 (X ) T. Radtke (7294) cc: ( X ) M. Mcghee (7198) ( x Unit 1 SM (7198)
(X ) M. Grigsby (7298) ( x Unit 2 SM (7298)
(X ) P. Kirker (7398) ( x Unit 3 SM (7398)
(X ) Training (7894) ( x Standards (7848)
(X) D. Vogt (7833) ( x Site Manager (7298)
(X ) P. Carpenter (7294) ( x Work Control 7298)
REQUIRED: ( X ) LICENSED X ) NON-LICENSED Several issues have been identified concerning the E-Plan activities on June 14, 2004. The attachment to this night order provides a current summary of the human performance issues identified to date followed by some additional facts that further complicated the event. At this point in the investigation, there are limited recommendations to overcome the identified issues. The purpose of providing this issues list is to make our On-shift organization aware of the problems encountered in dealing with a multi-unit E-Plan event. The only formal change made thus far concerning this event is that the Autodialer is now required to be activated for an Alert or higher classification. There is no longer an option to omit this action during normal working hours. Other changes and training will be forthcoming as the investigation team identifies recommendations to overcome these issues.
One point in the current EPIP-01 needs to be emphasized. Step 3.1 states: "For those situations involving more than one unit, the Unit 1 Shift Manager is responsible for initially classifying and declaring the emergency and assuming the position of Onshift EC." In any E-Plan event, we can have only one EC. If an event impacts more than one unit, the individuals classifying the events in the affected units must be in communication with the Unit I Shift Manager who will assume the EC role and will therefore be responsible for the notification to our offsite agencies.
Please direct any questions or concerns to Dave Callaghan, x6306.
Information inthis record was deleted Digitally signed by: Callaghan. David M(ZI 9590) inaccordance with he Freedom of Infogsnation Date: 07d0112004 0Z;4O Act, exemptions Reason: I am the au=horfWs dowcnent Location: PVNGS '; FORY - DA T)E -
Ij INITIATED BY CANCELLED :BY DATE DISPOSITION
( ) PROCEDURE REVISION REQUIRED, CANCEL WHEN COMPLETE
( ) REVIEW COMPLETED, CANCEL
( ) NO LONGER APPLICABLE
( ) EVENT/ EVOLUTION COMPLETED, CANCEL us IS 13
070104 NO Attachment CRDR 2715749 Human Performance Issues
- Ul SM did not assume the site EC role for the on-shift organization as required by EPIP-01 for events impacting more than one unit.
- Ul NUE notification was not accomplished due to a miscommunication. Ul SM did not speak directly to the U2 SM.
- U3 NUE notification was independently communicated and exceeded the allowed 15 minutes.
- The U3 EALs exceeded were 2-1 (LOOP) and 8-2 (ESD) but only the 2-1 EAL was communicated.
- The Autodialer was not activated as required for an Alert.
- Previous maintenance on the TSC backup diesel left the "run / idle" switch in the "idle" position. The diesel did not energize the TSC power which resulted in overheating and it
. tripped.
- EALs 2-3 and 2-1 were inappropriately communicated to the state agencies when U2 downgraded from the Alert.
CRDR 2715749 Other Issues
- The EPIP-O1 procedure flow and the notification forms do not support the UI SM assuming the site EC role for the on-shift organization. Each unit SM is trained to act as an independent entity.
- The NAN phone is not designed to work during a loss of off-site power.
- There is no easy method for the 3 unit Shift Managers to confer with each other to make a common notification to the off-site agencies.
- Loss of power to the CR computers prevented the timely use of the E-Plan pagers (Wpage). This was eventually completed from the OSB when it was understood that construction power was still available to the site. The Autodialer is the backup for the Wpage function but this was not identified in the procedure.
[A Digitally signed by eIiagh~an, David M(Z19590)
Date: 07/01/2004 &?7,3Q0 Reason: I am the author gIthls document Location: PVNGS J
!I,
