ML093620814
| ML093620814 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 12/28/2009 |
| From: | Boland A Division of Reactor Safety III |
| To: | Allen B FirstEnergy Nuclear Operating Co |
| References | |
| EA-09-283 IR-09-503 | |
| Download: ML093620814 (23) | |
See also: IR 05000346/2009503
Text
UNITED STATES
NUCLEAR REGULATORY COMMISSION
REGION III
2443 WARRENVILLE ROAD, SUITE 210
LISLE, IL 60532-4352
December 28, 2009
Mr. Barry Allen
Site Vice President
FirstEnergy Nuclear Operating Company
Davis-Besse Nuclear Power Station
5501 North State Route 2, Mail Stop A-DB-3080
Oak Harbor, OH 43449-9760
SUBJECT: DAVIS-BESSE NUCLEAR POWER STATION
NRC INSPECTION REPORT 05000346/2009503(DRS)
Dear Mr. Allen:
On November 23, 2009, the U. S. Nuclear Regulatory Commission (NRC) completed an
inspection conducted onsite August 4 through 6, 2009, of an event that occurred at your
Davis-Besse Nuclear Power Station on June 25, 2009. The purpose of the inspection was to
review the events, circumstances, and licensee actions associated with an explosion in the
switchyard and subsequent Alert declaration. The enclosed report documents the inspection
findings which were discussed on November 23, 2009, with you and other members of your
staff.
The inspection examined activities conducted under your license as they relate to safety and
compliance with the Commissions rules and regulations and with the conditions of your license.
The inspectors reviewed selected procedures, records, audio tapes, and interviewed personnel.
The enclosed report presents the results of the inspection including a finding that preliminarily
has been determined to be White, a finding with low to moderate increased safety significance
that may require additional NRC inspections. As described in Section 4OA3 of this report, the
finding involves the failure to implement the emergency classification and action level scheme
during an actual event for an explosion in the switchyard. The operators failed to verify, assess,
and classify the situation in conjunction with the Davis-Besse Emergency Plan Table of
Emergency Action Level Conditions. Specifically, immediately following an electrical fault and
catastrophic failure of a voltage transformer in the switchyard resulting in an explosion, fires,
and damage to several switchyard components which affected plant operations, the operators
failed to recognize the hazard to the stations operations met the emergency action level
conditions for declaring an Alert. After the finding was identified, your staff implemented
corrective actions to ensure the finding did not present an immediate safety concern. The
finding was assessed based on the best available information using the Emergency
Preparedness Significance Determination Process (SDP).
B. Allen -2-
The finding is also an apparent violation of NRC requirements and is being considered for
escalated enforcement action in accordance with the Enforcement Policy, which can be found
on the NRCs website at http://www.nrc.gov/about-nrc/regulatory/enforcement/enforce-pol.html.
In accordance with NRC Inspection Manual Chapter (IMC) 0609, Significance Determination
Process, we intend to complete our evaluation using the best available information and issue
our final determination of safety significance within 90 days of the date of this letter. The
significance determination process encourages an open dialogue between the NRC staff and
the licensee; however, the dialogue should not impact the timeliness of the staffs final
determination.
Before we make a final decision on this matter, we are providing you with an opportunity:
(1) to attend a Regulatory Conference where you can present to the NRC your perspective on
the facts and assumptions the NRC used to arrive at the finding and assess its significance, or
(2) submit your position on the finding to the NRC in writing. If you request a Regulatory
Conference, it should be held within 30 days of the receipt of this letter and we encourage you
to submit supporting documentation at least one week prior to the conference in an effort to
make the conference more efficient and effective. If a Regulatory Conference is held, it will be
open for public observation. If you decide to submit only a written response, such submittal
should be sent to the NRC within 30 days of your receipt of this letter. If you decline to request
a Regulatory Conference or submit a written response, you relinquish your right to appeal the
final SDP determination, in that by not doing either, you fail to meet the appeal requirements
stated in the Prerequisite and Limitation sections of Attachment 2 of IMC 0609.
Please contact Mr. Hironori Peterson at (630) 829-9707 within ten days from the issue date of
this letter to notify the NRC of your intentions. If we have not heard from you within ten days,
we will continue with our significance determination and enforcement decision. The final
resolution of this matter will be conveyed in separate correspondence.
Because the NRC has not made a final determination in this matter, no Notice of Violation is
being issued for this inspection finding at this time. In addition, please be advised that the
characterization of the apparent violation described in the enclosed inspection report may
change as a result of further NRC review.
Based on the results of this inspection, two additional findings of very low safety significance
were also identified, one NRC identified and one licensee identified. The findings involved
violations of NRC requirements; however, because of the very low safety significance and
because the issues were entered into your corrective action program, the NRC is treating the
issues as Non-Cited Violations (NCVs) in accordance with Section VI.A.1 of the NRC
If you contest the subject or severity of the NCVs, you should provide a response within 30 days
of the date of this inspection report, with the basis for your denial, to the U. S. Nuclear
Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001, with a
B. Allen -3-
copy to the Regional Administrator, U. S. Nuclear Regulatory Commission - Region III, 2443
Warrenville Road, Suite 210, Lisle, IL 60532-4352; the Director, Office of Enforcement, U. S.
Nuclear Regulatory Commission, Washington, DC 20555-0001; and the Resident Inspector
Office at the Davis-Besse Nuclear Power Station. In addition, if you disagree with the
characterization of any finding in this report, you should provide a response within 30 days of
the date of this inspection report, with the basis for your disagreement, to the Regional
Administrator, Region III, and the NRC Resident Inspector at the Davis-Besse Nuclear Power
Station. The information that you provide will be considered in accordance with Inspection
Manual Chapter 0305, Operating Reactor Assessment Program.
In accordance with 10 CFR 2.390 of the NRCs Rules of Practice, a copy of this
letter, its enclosures and your response (if any) will be made available electronically for public
inspection in the NRC Public Document Room or from the Publicly Available Records (PARS)
component of NRCs document system (ADAMS), accessible from the NRC Web site at
http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Anne T. Boland, Director
Division of Reactor Safety
Docket No. 50-346
License No. NPF-3
Enclosures:
1. Inspection Report 05000346/2009-503
w/Attachment: Supplemental Information
2. Sequence of Events
cc w/encls: Distribution via ListServ
U. S. NUCLEAR REGULATORY COMMISSION
REGION III
Docket No: 50-346
License No: NPF-3
Report No: 05000346/2009-503
Licensee: FirstEnergy Nuclear Operating Company (FENOC)
Facility: Davis-Besse Nuclear Power Station
Location: Oak Harbor, OH
Dates: August 4, 2009 through November 23, 2009
Inspector: Regina Russell, Emergency Preparedness Inspector
Approved by: Hironori Peterson, Chief
Operations Branch
Division of Reactor Safety
Enclosure 1
TABLE OF CONTENTS
ENCLOSURE 1
SUMMARY OF FINDINGS1
REPORT DETAILS 3
4OA3 Follow-Up Of Events...3
.1 Explosion of the J Bus Transformer..3
a. Inspection Scope..3
b. Event Description..3
c. Findings..4
- Emergency Classification .4
- Notification of State and Local Agencies7
4OA6 Management Meetings...9
4OA7 Licensee-Identified Violation..9
ATTACHMENT - SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT1
LIST OF ITEMS OPENED, CLOSED AND DISCUSSED1
LIST OF DOCUMENTS REVIEWED...2
LIST OF ACRONYMS USED4
ENCLOSURE 2
SEQUENCE OF EVENTS.1
i
SUMMARY OF FINDINGS
IR 05000346/2009-503(DRS); 08/04/2009 - 11/23/2009; Davis-Besse Nuclear Power Station;
Event Follow-up Inspection
The report covers an event follow-up inspection by a regional emergency preparedness
inspector. The inspection identified one preliminary White finding with an associated Apparent
Violation (AV), one Green finding with an associated Non-Cited Violation (NCV), and one
Severity Level IV finding with an associated NCV of NRC regulations. The significance of most
findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, Significance Determination Process (SDP), and the cross-cutting aspect was
determined using IMC 0305, Operating Reactor Assessment Program. Findings for which the
SDP does not apply may be Green or be assigned a severity level after NRC management
review. The NRCs program for overseeing the safe operation of commercial nuclear power
reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4, dated
December 2006.
Cornerstone: Emergency Preparedness
- Preliminary White. A licensee identified finding and associated Apparent Violation (AV)
of 10 CFR 50.54(q) and 10 CFR 50.47(b)(4) was identified for the failure to implement
the emergency classification and action level scheme during an actual event to declare
an Alert after an explosion in the switchyard. The operators failed to verify, assess, and
classify the situation in conjunction with the Davis-Besse Emergency Plan Table of
Emergency Action Level Conditions. Specifically, immediately following an electrical
fault and catastrophic failure of a voltage transformer in the switchyard resulting in an
explosion, fires, and damage to several switchyard components which affected plant
operations, the operators failed to recognize the hazard to the stations operations met
the emergency action level conditions for declaring an Alert. The station entered a
Limiting Condition for Operation per Technical Specifications.
The finding was screened to be more than minor because the failure to declare an Alert
adversely affected the Reactor Safety - Emergency Preparedness Cornerstone objective
to ensure the licensee is capable of implementing adequate measures to protect the
health and safety of the public during a radiological emergency. The performance
deficiency has the attribute of Emergency Response Organization Performance
associated with Actual Event Response. The performance deficiency involving the
failure to properly utilize the emergency classification and action level scheme during an
actual Alert meets the criteria of the Emergency Preparedness SDP for a failure to
implement a risk significant planning standard of event classification. The failure to
classify was a result of the licensees errors in recognition, was not due to competing
safety-related activities, and denied offsite authorities the opportunity to make decisions
regarding protecting public health and safety. The finding was screened to be a failure
to implement the risk significant planning standard associated with classification at the
Alert level and was screened to be preliminarily White. Additionally, the cause of the
deficiency had a cross-cutting component in the area of Human Performance.
Specifically, the licensee failed to make safety-significant decisions using a systematic
process and failed to obtain adequate reviews on the decisions (H.1(a)). (Section 4OA3)
1 Enclosure 1
- Green. The inspector identified a finding and an associated NCV of 10 CFR 50.54(q)
and 10 CFR 50.47 (b)(5) for the licensees failure to maintain adequate emergency
procedures to comply with emergency planning requirements to ensure timely
notifications to State and local governmental agencies. Although the licensees
emergency classification procedure implied that State and local notifications should be
made promptly, the procedure did not prescribe the notification time frame in which a
missed classification should be made; as a result, the required notifications were not
completed for over four hours.
The finding was screened to be more than minor because the deficiency adversely
affected the Reactor Safety - Emergency Preparedness Cornerstone objective to ensure
the licensee is capable of implementing adequate measures to protect the health and
safety of the public during a radiologic emergency. The deficiency has the attribute of
Procedure Quality associated with procedure use in an actual event. The Failure to
Comply branch of the Emergency Preparedness SDP flowchart was used because the
program element for offsite notification was not adequate as designed for all types of
events, such as in the case of an after-the-fact or missed event declaration. Because
the emergency conditions no longer existed at the time of the event classification and
notification recognition, the compliance with emergency plan requirements for notification
was evaluated as non-risk significant for the switchyard event. The performance
deficiency was evaluated to be a planning standard degraded function and to be Green.
State and local offsite governmental officials were not able to assess conditions at the
time of the late event declaration and make informed decisions concerning the offsite
response. Additionally, the finding had a cross cutting component in the Human
Performance area of Resources. Specifically, the licensees procedures for notification
to offsite agencies were not complete (H.2(c)). (Section 4OA3)
Licensee-Identified Violation
A violation of very low safety significance that was identified by the licensee has been reviewed
by inspectors. Corrective actions planned or taken by the licensee have been entered into the
licensees corrective action program. This violation and corrective action tracking number is
listed in Section 4OA7 of this report.
2 Enclosure 1
REPORT DETAILS
4. OTHER ACTIVITIES
4OA3 Follow-Up of Events (71153)
.1 Explosion of the J Bus Transformer
a. Inspection Scope
The inspector reviewed the circumstances including the sequence of events and
licensee actions associated with the Alert declaration on June 25, 2009, following the
switchyard explosion of the J bus transformer. The inspector interviewed fourteen
personnel and reviewed selected procedures, records, audio tapes, and written
statements. The inspection was conducted onsite August 4 through 6, 2009, and
continued with in-office reviews until November 23, 2009. The purpose of the inspection
was to evaluate the licensees event response actions for compliance with applicable
regulatory and Davis-Besse Emergency Plan requirements. A detailed event timeline
has been included in the Enclosure 2. Documents reviewed in this inspection are listed
in the Attachment - Supplemental Information.
This event follow-up review constituted 1 sample as defined in IP 71153-05.
b. Event Description
On June 25, 2009, at 12:49 a.m., the control room operators received annunciator
alarms in the control room indicating the de-energization of the J bus in the switchyard.
The loss of the J bus was caused by an electrical fault and catastrophic failure of the
Coupling Capacitor Voltage Transformer (CCVT) in the Coupling Capacitor Potential
Device (CCPD) used for voltage monitoring on the B phase of the bus. Two air circuit
breakers opened and the 345 kV breaker tripped resulting in loss of the J bus and
unavailability of one of two start-up transformers used to tie in offsite power. The station
entered Technical Specifications (TS) for a single point vulnerable configuration for
offsite alternating current (AC) power and a Limiting Condition for Operation (LCO) with
a 72-hour action statement.
At the onset of the event, reports of an explosion in the switchyard were immediately
called into the Secondary Alarm Station (SAS) by various security officers. The roving
officers and those at the posts reported the explosion, a white flash, a loud noise,
flames, and building vibrations. The SAS operator then called the control room and
reported fires throughout the switchyard, debris spread throughout the area, and a
breaker on fire. Security called for offsite fire and emergency medical services per the
control rooms request. Ottawa County responded with police, fire, and emergency
medical services.
The control room dispatched operations personnel to investigate the occurrence in the
switchyard and provide an assessment of magnitude of the fire, the need for offsite
assistance, and the extent of component damage. The control room also dispatched fire
brigade personnel to the switchyard. The fire brigade extinguished the flames using
hand held fire extinguishers and allowing other smaller fires to extinguish themselves.
The licensee did not use the offsite fire assistance and released the offsite responders.
3 Enclosure 1
The control room alerted the assigned duty team of the events in the switchyard and the
need for their response to the site. The outage control center was manned in order to
provide support and assistance to the transmission and distribution company that
responded for repair and restoration of the bus.
After receiving reports of the fire and considering the request which had been made for
offsite fire assistance, the Shift Manager referred to the emergency plan and
classification scheme and noted the criteria for an Unusual Event classification under the
Hazards to Station Operations category of Fire would be met if the offsite fire
company was used in extinguishing the fires. When the offsite assistance was not used,
the Shift Manager again noted that no emergency criteria were met for the emergency
plan. The Shift Technical Advisor performed a peer review and arrived at the same
conclusions as the Shift Manager for no need of event classification. The conditions for
an Alert were met under Onsite explosion affecting plant operations because: (1) the
control room was informed by station personnel who made a visual sighting of the
explosion; and (2) instrumentation readings in the control room indicating equipment
problems which required entry into a 72-hour TS LCO.
When the oncoming Shift Manager reviewed the events with the assistance of the
Emergency Preparedness Manager, the oncoming Shift Manager realized the entry
criteria for a classification at the Alert level were met.
The Shift Manager notified the NRC Headquarters Operations Officer of a transitory Alert
at 11:44 hours on June 25, 2009, pursuant to 10 CFR 50.72 (a)(1)(i) and based on
Emergency Action Level 7.D.2, Onsite explosion affecting plant operations. The
Emergency Preparedness Manager along with plant management notified Ottawa
County, Lucas County, and the State of Ohio by a phone conference call.
c. Findings
The inspector identified two findings.
- Emergency Classification
Introduction: A licensee-identified preliminarily White finding with low to moderate
safety significance and associated Apparent Violation (AV) of 10 CFR 50.54(q) and
10 CFR 50.47(b)(4) was identified for the failure to implement the emergency
classification and action level scheme during an actual event for an explosion in the
switchyard. The operators failed to verify, assess, and classify the situation and
recognize the event met the emergency action level conditions for declaring an Alert.
Description: On June 25, 2009, during an actual explosion event, the Shift Manager
failed to verify indications of the off-normal event and reported sightings and failed to
perform an extensive assessment as necessary to determine the applicable emergency
classification level. The Shift Manager failed to recognize the fire and debris throughout
the switchyard and areas outside the switchyard were a result of a transformer
explosion; therefore, he failed to consider the emergency actions levels for Explosion
under the Hazards to Station Operations category. The conditions for the Alert were
met under Onsite explosion affecting plant operations because: (1) the control room
was informed by station personnel who made a visual sighting of the explosion; and
(2) instrumentation readings in the control room indicating equipment problems.
4 Enclosure 1
An electrical fault and catastrophic failure of the transformer for voltage monitoring on
the B phase of the J bus resulted in an explosion and fires. The event resulted in two
breakers opening, damage to several switchyard components, one of two switchyard
buses used to tie in offsite power becoming de-energized, and the required entry into a
72-hour TS LCO.
The Shift Manager and Shift Technical Advisor considered the emergency classification
related to the switchyard fires but failed to recognize the explosion. They determined the
conditions requiring emergency classification for fire were not met because offsite fire
assistance was not used. The Shift Manager failed to verify the indications, assess the
overall impact to the facility, and evaluate other entry criteria in the Hazards to Station
Operations category of the emergency classification scheme. The Shift Technical
Advisor performed a peer review and arrived at the same conclusions as the Shift
Manager that no event classification was warranted. Essentially, the Shift Technical
Advisor performed a peer check on the use of the classification table focusing on a Fire
hazard and did not perform an independent assessment. He did not re-evaluate the
initiating conditions and information received from the field to make an emergency
classification evaluation.
The control room crew had an opportunity to realize an explosion had occurred at 00:50
hours when the SAS operator informed the control room of the explosion and fires in the
switchyard and subsequently requested offsite fire assistance. The determination was
based on the site protection incident report, emergency phone call report which indicated
the Shift Manager was notified, and interviews conducted by the inspector, Based on
interviews with the inspector, the SAS operator said he told the control room an
explosion had occurred, as well as, the Shift Security Supervisor reported he told the
Shift Manager. The Shift Security Supervisor also reported to the Duty Team Director,
who represented senior management for emergency response, an explosion had
occurred (recorded phone call). The Duty Team Director had subsequent calls to the
control room.
The operating crew had numerous opportunities to gain and assess information to
properly classify the explosion. On the initial call and subsequent calls to the control
room from Security, the reactor operator in the control room on the phone to Security
reported he was not concerned with what had caused the wide spread fires but was
focused on what to do to put out the fires and actions to ensure plant stability. When
Operations personnel and the Fire Captain, a Senior Reactor Operator (SRO), were sent
to the switchyard and reported back their assessment at 01:47 hours, the control room
was provided enough information to conclude an explosion had occurred. Based on
interviews with the inspector, the Fire Captain stated he knew a transformer had an
electrical fault that catastrophically failed, caused damage to many components, and
spread debris and fire in a large area, but in his mind, he did not consider this an
explosion. He was unaware of the definition of explosion in the licensees procedure.
The licensees procedure for explosions, RA-EP-02840, defines Explosion: A rapid,
violent, unconfined combustion, or catastrophic failure of pressurized/energized
equipment that imparts sufficient force to potentially damage permanent structures,
systems, or components.
Analysis: The inspector concluded the failure to use the emergency action level scheme
to classify an Alert when conditions warranted due to an explosion during an actual
event was a performance deficiency. Even though indications were available to the
5 Enclosure 1
control room at 00:50 hours, the event was not recognized as meeting the Alert criteria
until 07:50 hours. The performance deficiency was screened using the Emergency
Preparedness SDP. The performance deficiency was screened to be more than minor
because the performance deficiency adversely affected the Reactor Safety - Emergency
Preparedness Cornerstone objective to ensure the licensee is capable of implementing
adequate measures to protect the health and safety of the public during a radiologic
emergency. The performance deficiency has the attribute of Emergency Response
Organization Performance associated with Actual Event Response.
The performance deficiency involving the failure to properly utilize the emergency
classification and action level scheme during an actual Alert meets the SDP criteria for a
failure to implement a risk significant planning standard of event classification. The
failure to classify was a result of the licensees errors in recognition, was not due to
competing safety-related activities, and denied offsite authorities the opportunity to make
decisions regarding protecting public health and safety, therefore, was assessed as a
failure to implement the emergency plan classification scheme. The Program Element of
the emergency classification scheme was adequate as designed and met the planning
standard function.
IMC 0609, Appendix B - The Actual Event Implementation Problem branch of the SDP
was used because failure to comply with a regulatory requirement occurred during an
actual event. Using the SDP, Appendix B, Sheet 2, Actual Event Implementation
Problem flowchart, the performance deficiency screened to be an actual event
implementation problem associated with classification at the Alert level and a failure to
implement a risk significant planning standard, therefore, was screened as a preliminary
White finding. As a result of not declaring an Alert, Davis-Besse failed to activate their
full emergency response organization to assist in mitigating the event. Additionally,
State and local offsite agencies were not able to take initial offsite measures to assess
conditions, staff their facilities, and make informed decisions for protecting public safety.
The cause of the deficiency had a cross-cutting component in the area of Human
Performance. Specifically, the licensee failed to make safety-significant decisions using
a systematic process and failed to obtain adequate reviews on the decisions (H.1(a)).
Enforcement: Title 10 CFR 50.47(q) requires, in part, a licensee authorized to possess
and operate a nuclear power reactor shall follow and maintain in effect emergency plans
which meet the standards in 10 CFR 50.47(b). Title 10 CFR 50.47(b)(4) requires, in
part, a standard emergency classification and action level scheme be used by the
licensee. Davis-Besse Nuclear Power Station Emergency Plan section 2.6 states, in
part, detailed actions to be taken by individuals in response to onsite emergency
conditions are described in the emergency plan implementing procedures. Davis-Besse
Nuclear Power Station Emergency Plan Implementing Procedure, RA-EP-01500,
Emergency Classification requires, in part, that when indications of abnormal
occurrences are received by the control room staff, the Shift Manager shall verify the
indications of the off-normal event or reported sighting, assess the information available
from valid indications or reports, and classify the situation. The Emergency Plan Table
of Emergency Action Level Conditions for Explosion under the Hazards to Station
Operations category requires, in part, the declaration of an Alert for an onsite explosion
affecting plant operations in all modes with the: (1) control room being informed by
station personnel who have made a visual sighting; and (2) instrumentation readings on
plant systems indicating equipment problems.
6 Enclosure 1
Contrary to the above, from the time period of 00:50 to 01:47 hours on June 25, 2009,
the Shift Manager failed to verify the indications of the off-normal event or reported
sighting, assess the information available from valid indications or reports of an
explosion, and classify the situation as an Alert in accordance with the Davis-Besse
Emergency Plan Table of Emergency Action Level Conditions during an actual event.
Specifically, the valid indications and reports included: (1) the control room being
informed by Security personnel of a visual sighting of an explosion in the switchyard;
(2) instrumentation readings and annunciators in the control room that indicated the loss
of the J bus; and (3) onsite field reports from the equipment operator and from the Fire
Brigade Captain of catastrophic failure of a transformer and debris. As a consequence,
Davis-Besse failed to activate their full emergency response organization to assist in
mitigating the event. Additionally, State and local offsite agencies which rely on
information provided by the facility licensee were not able to take initial offsite measures.
The finding is identified as an apparent violation of low to moderate safety significance.
(AV 05000346/ 2009503-01)
- Notification of State and Local Agencies
Introduction: An NRC- identified finding of very low safety significance (Green) with an
associated NCV was identified for the licensees failure to comply with emergency
planning requirements to ensure timely notifications to State and local governmental
agencies. Following the licensees after-the-fact recognition of the Alert, the licensee
recognized notifications needed to be made to State and local response organizations;
however, the procedures failed to provide clear and consistent guidance for the
notification timeliness. As such, the notifications were not completed for more than four
hours.
Description: At 07:50 hours on June 25, 2009, approximately eight hours after the
switchyard explosion had occurred and mitigating actions were completed by the
operating crew, the licensee realized they had failed to classify and declare an Alert. By
this time, the licensee had many managers and responder personnel onsite reviewing
the events and circumstances of the explosion. At 07:50 hours, the Shift Manager noted
in the control room unit log, information for notification to the State of Ohio, Ottawa
County, and Lucas County were to be collected and the after-the-fact notifications were
to be made by the Emergency Offsite Manager who was designated for the event to be
Emergency Preparedness Manager for the site.
The Davis-Besse Emergency Plan and emergency plan implementing procedures
designate the responsible individual for offsite notification. The Emergency Plan states,
in part, the Shift Manager, acting as the Emergency Director, will implement the plan and
ensure that required notifications to the counties and State are made. However, the
Emergency Classification procedure in the section for Transitory Events states, in
part, if through an event review an emergency classification was discovered as missed,
the Shift Manager, or designee, will contact the Emergency Offsite Manager (EOM).
The EOM will perform the required notifications to the offsite agencies. The EOM as
described in the Emergency Plan was a position associated with activation of the
Emergency Response Organization. For the after-the-fact Alert declaration for the
switchyard explosion event on June 25, 2009, the Emergency Response Organization
was not activated.
7 Enclosure 1
The Emergency Plan and emergency plan implementing procedures did not provide
clear consistent guidance for required notification timeliness. In the Emergency Plan,
the specific agencies to notify are listed along with the time requirement of 15 minutes.
The emergency plan implementing procedure Emergency Notification states, in part,
the initial notification of the State and Counties is required within 15 minutes of the
declaration of an emergency. The Emergency Classification procedure has a caution
that states, in part, if a transitory event has occurred a notification to the offsite agencies
is still required. In contrast, the Emergency Classification procedure in the Transitory
Event section discusses the notification to the offsite organizations will be made by
phone or if the agency cannot be contacted, the notification will be faxed with a follow-up
phone call the following morning. The procedure implies the notification will be made
promptly following the gathering of the notification information, but does not clearly state
the time requirement. Even though the licensee defined the after-the-fact classification
as a transitory Alert, the declaration had the 15-minute notification time requirement as
noted in the Emergency Notification procedure and the Emergency Plan. The
Emergency Preparedness Manager acting as the EOM reported he did not have the
sense of timeliness for the required notification and lost track of time. The notification of
the after-the-fact Alert declaration was made at 12:30 hours to the State and local
governmental agencies through a conference call. The notification was not made using
the Initial Notification form, DBEP-010, as required by the licensees procedure.
Analysis: The inspector concluded the failure to comply with emergency planning
requirements to have adequate procedures to ensure timely notifications to State and
local governmental agencies was a performance deficiency. The deficiency did not meet
the criteria for traditional enforcement, therefore, was screened using the Emergency
Preparedness SDP. The deficiency was screened to be more than minor because the
deficiency adversely affected the Reactor Safety - Emergency Preparedness
Cornerstone objective to ensure the licensee is capable of implementing adequate
measures to protect the health and safety of the public during a radiologic emergency.
The deficiency has the attribute of Procedure Quality associated with procedure use in
an actual event. The delay to notify the offsite agencies was not a result of the
licensees errors in recognition and was not due to competing safety-related activities.
Even after the licensee recognized State and local notifications needed to be made,
offsite notifications were delayed for over four hours.
IMC 0609, Appendix B - The Failure to Comply branch of the SDP was used because
the program element for offsite notification was not adequate as designed for all types of
events, such as in the case of an after-the-fact or missed event declaration. The
licensee did not comply with a regulatory requirement to have adequate procedures to
ensure timely notifications to State and local governmental agencies for all event types.
Because the emergency conditions no longer existed at the time of the event
classification and notification recognition, the compliance with emergency plan
requirements for notification was evaluated as non-risk significant for the switchyard
event. Using the SDP, Appendix B, Sheet 1, Failure to Comply flowchart, the
performance deficiency was evaluated to be a planning standard degraded function,
therefore, was screened to be of very low safety significance (Green). State and local
offsite governmental officials were not able to assess conditions at the time of the late
event declaration and make informed decisions concerning the offsite response.
The performance deficiency involving the licensees failure to have adequate procedures
to ensure timely notifications to State and local governmental agencies for all declared
8 Enclosure 1
events had a cross cutting component in the Human Performance area of Resources.
Specifically, the licensees procedures for notification to offsite agencies were not
complete. (H.2(c))
Enforcement: Title 10 CFR 50.47(q) requires, in part, a licensee authorized to possess
and operate a nuclear power reactor shall follow and maintain in effect emergency plans
which meet the standards in 10 CFR 50.47(b). In accordance with 10CFR 50.47(b)(5),
procedures have been established for notification of State and local response
organizations. Also 10 CFR Part 50, Appendix E.D.3., requires the capability to notify
responsible State and local governmental agencies within 15 minutes after declaring an
emergency.
Contrary to the above, the licensee did not maintain adequate procedures to ensure
timely notifications to State and local governmental agencies for all declared events.
For the after-the-fact Alert declaration for the switchyard explosion event on
June 25, 2009, the notifications to State of Ohio, Ottawa County, and Lucas County
were delayed for over four hours after the Shift Manager noted the requirement.
Because the finding was of very low safety significance and has been entered into the
licensees corrective action program (CR 09-62918), the violation is being treated as a
Green NCV (NCV 05000346/ 2009503-02, Failure to Have Adequate Procedures for
Offsite Notifications), in accordance with Section VI.A.1 of the NRC's Enforcement
Policy.
4OA6 Management Meetings
.2 Exit Meeting Summary
On August 6, 2009, the inspector provided an interim debrief to the licensee staff for the
onsite interview portion of the inspection. On November 23, 2009, the inspector
presented the inspection results to the Site Vice President, Mr. B. Allen, and other
members of the licensee staff. The licensee acknowledged the issues presented. The
inspector confirmed that none of the potential report inputs which were discussed was
considered proprietary.
4OA7 Licensee-Identified Violation: A violation of very low safety significance (Severity
Level IV) was identified by the licensee and was a violation of NRC requirements which
meets the criteria of Section VI of the NRC Enforcement Policy. A violation of
10 CFR 50.72 was identified for failure to provide timely notification to the NRC. On
June 25, 2009, Davis-Besse failed to provide timely notification to the NRC of the
after-the-fact Alert classification resulting from an explosion in the switchyard. The
delayed notification was not a result of competing safety-related activities, plant
stabilization activities, or equipment failures. The delayed notification was not a result of
the licensees initial failure to classify the event. At 07:50 hours the licensee recognized
that conditions warranted the classification of an Alert and they had missed the Alert
declaration; however, the licensee did not notify the NRC of the missed Alert until
11:44 hours, a period exceeding one hour notification requirement.
The finding was evaluated using the traditional enforcement process because the
deficiency had the potential to impact the NRCs ability to perform its regulatory function.
Since the emergency condition no longer existed at the time the report was required and
the report was untimely versus not reported at all, the issue was characterized as a
9 Enclosure 1
violation of very low safety significance (SL IV) and as a NCV. The licensee entered the
issue into their corrective action program (CR 09-61112).
ATTACHMENT: SUPPLEMENTAL INFORMATION
10 Enclosure 1
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee
B. Allen, Site Vice President
R. Patrick, Operations Superintendent
G. Wolf, Regulatory Compliance Supervisor
D. Wuokko, Regulatory Compliance Supervisor
V. Kaminskas, Engineering Director
J. Vetter, Emergency Preparedness Manager
M. Parker, Security Manger
B. Boles, Site Operations Director
C. Price, Performance Improvement director
G. Halnon, Regulatory Affairs Director
T. Schneider, Public Affairs
D. Dewitz, Senior Nuclear Specialist
Nuclear Regulatory Commission
H. Peterson, Chief Operations Branch
J. Rutkowski, Senior Resident Inspector
LIST OF ITEMS OPENED, CLOSED AND DISCUSSED
Opened
05000346/ 2009503-01 AV Failure to Use Classification Scheme for an Alert
05000346/ 2009503-02 NCV Inadequate Procedures for State and Local Notifications
Closed, and Discussed
05000346/ 2009503-02 NCV Inadequate Procedures for State and Local Notifications
1 Attachment
LIST OF DOCUMENTS REVIEWED
The following is a list of documents reviewed during the inspection. Inclusion on this list does
not imply that the NRC inspectors reviewed the documents in their entirety, but rather, that
selected sections of portions of the documents were evaluated as part of the overall inspection
effort. Inclusion of a document on this list does not imply NRC acceptance of the document or
any part of it, unless this is stated in the body of the inspection report.
4OA3 Follow-Up of Events
Davis-Besse Nuclear Power Station Emergency Plan; Revision 26
RA-EP-01500; Emergency Classification; Revision 10
RA-EP-02110; Emergency Notification; Revision 9
RA-EP-02840; Emergency Plan Off Normal Procedure; Explosion; Revision 3
NOP-LP-5003; Communicating Events of Potential Public Interest; Revision 1
Integrated On-Call Report; Responder Team C/Blue; dated June 25, 2009
Control Room Unit Log; June 25, 2009, through June 26, 2009
June 25, 2009 Alert Timeline; dated July 27, 2009
DB-0095-01; Reactor Plant Event Notification Worksheet; dated June 25, 2009
FENOC Site Protection Incident Reports and Statements from Security Personnel
DB-0700-0; Emergency Phone Call Report; dated June 25, 2009
CR 09-61025; Loss of J Bus, Catastrophic Failure of J Bus Phase Potential Device;
dated June 25, 2009
CR 09-61038, Davis-Besse Site Protection to Critique Opportunities for Improvement on
Response to Switchyard Event; dated June 25, 2009
CR 09-61115; Transitory Alert Emergency Classification Following Loss of J Bus; dated
June 26, 2009
CR 09-62916; Lessons Learned: Switchyard Event NRC Follow-up Inspection;
Improvements to Relate Explosions to Emergency Action Levels; dated August 6, 2009
CR 09-62918, Lessons Learned - Switchyard Event NRC Follow-up Inspection;
Observation Concerning Notification Timeliness of State and Locals; dated
August 6, 2009
CR09-62919, Lesson Learned: Switchyard Event Follow-up - NRC Inspection;
Review Security Operations Strategies and Communications; dated August 6, 2009
CR09-63249; Re-evaluate June 25 Event on NRC Performance Indicator; dated
August 14, 2009
4OA7 Licensee-Identified Violation
DB-OP-00002; Operations Section Event/Incident Notifications and Actions; Revision 19
DBRM-RC-001; Regulatory Reporting Requirements; Revision 3
2 Attachment
NRC Event Notification Report for June 26, 2009
CR 09-61112; RA-EP-01500 Procedure Requires Additional Guidance; dated
June 26, 2009
CR 09-61200; NRC Notification Time for the 6/25/09 Alert Was Exceeded; dated
June 8, 2009
CA 09-61200; Human Performance Success Clock Evaluation Results; dated
July 1, 2009
CA 09-61200; Revise RA-EP-01500 to Strengthen Wording for NRC Notification; dated
July 24, 2009
3 Attachment
LIST OF ACRONYMS USED
ADAMS Agencywide Document Access Management System
CA Corrective Action
CAP Corrective Action Program
CCPD Coupling Capacitor Potential Device
CCVT Coupling Capacitor Voltage Transformer
CFR Code of Federal Regulations
CR Condition Report
DRP Division of Reactor Projects
IMC Inspection Manual Chapter
IR Inspection Report
NCV Non-Cited Violation
NEI Nuclear Energy Institute
NRC U. S. Nuclear Regulatory Commission
PARS Publicly Available Records System
SDP Significance Determination Process
UFSAR Updated Final Safety Analysis Report
URI Unresolved Item
4 Attachment
SEQUENCE OF EVENTS
June 24, 2009
Late on June 24, 2009, approximately two-and-a-half hours prior to midnight, a computer
point in the control room (E100) began to act erratically, first the computer point read off
scale high and later indicated a low voltage even thought the actual voltage in the J bus did
not change. The operators assumed the computer point was bad because the bus voltage
appeared unchanged.
June 25, 2009
At 00:48 hours, the control room lights flickered and a static noise was heard on the plant
address system. The Coupling Capacitor Potential Device (CCPD) catastrophically failed
causing a loss of the J bus and damage to switchyards components.
Within seconds, the Secondary Alarm Station (SAS) received reports of an explosion, a
white flash, a loud noise, flames, and building vibrations and flames in the switchyard.
At 00:49 hours, annunciator alarms were received indicating breaker openings, trips, and
the J bus (one of the two switchyard buses for offsite AC power) was de-energized. The
station entered a Limiting Condition for Operation per Technical Specifications for a single
point vulnerable configuration.
At 00:50 hours, as documented in the FENOC site protection incident report and per
interviews with the inspector, the SAS called to the Control Room and reported explosion
and flames throughout the switchyard. The Central Alarm Station (CAS) communicated with
security posts concerning an explosion.
Security requested offsite assistance from Ottawa County to dispatch Carroll Township fire
and Emergency Medical Services (EMS). The Control Room dispatched an equipment
operator to the switchyard to investigate the extent of the fire and equipment damage.
At 00:54 hours, the equipment operator reported fire, smoke, and debris spread throughout
whole end of the switchyard by the J Bus. The Shift Manager referred to the emergency
plan for Hazards (Fire) and noted conditions for an Unusual Event would be met if offsite fire
assistance (Carroll Township) is used to help extinguish the fires.
Following the initial report to the Control Room by SAS, per the interview with the inspector,
the Shift Security Supervisor indicated he communicated to the Shift Manager that the
explosion was apparently from equipment malfunction and was not from suspicious activity.
At 01:11 hours, Carroll Township Police Department was onsite.
At 01:19 hours, Carroll Township Fire Department was onsite.
At 01:20 hours, Carroll Township EMS was onsite.
The Duty Team Director responded to a page from the Shift Security Supervisor. The Duty
Team Director was the management representative on call. During the recorded telephone
conversation, the Shift Security Supervisor told the Director of the explosion in the
switchyard and the debris spread throughout the area. The explosion was apparently from
1 Enclosure 2
equipment malfunction and was not from suspicious activity. Carroll Township police, fire,
and EMS were onsite but not allowed into the switchyard and the fires were allowed to burn
out. Between 00:50 and 01:20 hours, the onsite Fire Captain, a Senior Reactor Operator
(SRO), arrived with the fire brigade to assess the damage and extinguish the fires.
At 01:23 hours, the Fire Captain reported all ground fires were extinguished.
At 01:24 hours, the Shift Manager noted no entry criteria met for event classification
because offsite fire assistance was not used. After his review, the Shift Manager asked the
Shift Technical Advisor to do a peer check. The Shift Technical Advisor peer check
confirmed no classification for the event due to fires.
At 01:26 hours, the CAS and SAS were advised offsite assistance was not needed.
At 01:27 hours, SAS called Ottawa County to cancel further response.
At 01:32 hours, the Carroll Township police, fire, and EMS left the site.
At 01:47 hours, the Fire Captain reported visible damage to J Bus A phase (oil leak),
C phase (damaged insulator), B phase (destroyed and debris throughout the property),
and C phase disconnect breaker (damaged insulator).
At 01:55 hours, the Shift Manager conducted a duty team phone call to provide updated
status of the plant. The Outage Control Center became manned with the Duty Plant
Manager, maintenance, and engineering to support the transmission and distribution
companys response to the switchyard explosion.
At 02:15 hours, the Shift Manager called on the phone to the Operations Manager and
discussed damage to switchyard components.
The control room continued to receive information from the field concerning the damage and
communicated with the duty team and proceeded to switch over to the remaining available
start-up transformer.
At 07:50 hours, further review of the events and the classification by the oncoming Shift
Manager in conjunction with the EP Manager, the licensee determined they met the
conditions for an emergency classification of an Alert for criteria 7.D.2 - Onsite explosion
affecting plant operations. Per the licensees procedures, the missed Alert was called a
transitory Alert. The Shift Manager noted the EP Manager would notify the State of Ohio,
Ottawa County, and Lucas County.
At 11:44 hours, the Shift Manager notified the NRC Headquarters Operations Officer
pursuant to 10 CFR 50.72 (a)(1)(i) of a transitory Alert based on Emergency Action Level
7.D.2- onsite explosion affecting plant operations.
At 12:30 hours, the EP Manager along with plant management, notified Ottawa County,
Lucas County, and the State of Ohio by a phone conference call.
2 Enclosure 2
B. Allen -3-
Warrenville Road, Suite 210, Lisle, IL 60532-4352; the Director, Office of Enforcement, U.S.
Nuclear Regulatory Commission, Washington, DC 20555-0001; and the Resident Inspector
Office at the Davis-Besse Nuclear Power Station. In addition, if you disagree with the
characterization of any finding in this report, you should provide a response within 30 days of
the date of this inspection report, with the basis for your disagreement, to the Regional
Administrator, Region III, and the NRC Resident Inspector at the Davis-Besse Nuclear Power
Station. The information that you provide will be considered in accordance with Inspection
Manual Chapter 0305, Operating Reactor Assessment Program.
In accordance with 10 CFR 2.390 of the NRCs Rules of Practice, a copy of this
letter, its enclosures and your response (if any) will be made available electronically for public
inspection in the NRC Public Document Room or from the Publicly Available Records (PARS)
component of NRCs document system (ADAMS), accessible from the NRC Web site at
http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Anne T. Boland, Director
Division of Reactor Safety
Docket No. 50-346
License No. NPF-3
Enclosures:
1. Inspection Report 05000346/2009-503
w/Attachment: Supplemental Information
2. Sequence of Events
cc w/encls: Distribution via ListServ
DISTRIBUTION:
See next page
SEE PREVIOUS CONCURRENCES
DOCUMENT NAME: G:\DRS\Work in Progress\Davis Besse IR2009-503 (1).doc
Publicly Available Non-Publicly Available Sensitive Non-Sensitive
To receive a copy of this document, indicate in the concurrence box "C" = Copy without attach/encl "E" = Copy with attach/encl "N" = No copy
OFFICE RIII RIII RIII RIII
NAME RRussell:co HPeterson SOrth ABoland
DATE 12/17/09 12/17/09 12/28/09 12/28/09
OFFICIAL RECORD COPY
1
Letter to Mr. Barry Allen from Ms. Anne Boland dated December 28, 2009
SUBJECT: DAVIS-BESSE NUCLEAR POWER STATION
SPECIAL INSPECTION REPORT 05000346/2009-503 PRELIMINARY
WHITE FINDING
DISTRIBUTION: Marvin Itzkowitz
RidsNrrDorlLpl3-2 Resource Catherine Scott
Susan Bagley Eric Leeds
RidsNrrPMDavisBesse Resource Bruce Boger
RidsNrrDirsIrib Resource Mary Ann Ashley
Cynthia Pederson Mark Satorius
Steven Orth Cynthia Pederson
Allan Barker Daniel Holody
Carole Ariano Carolyn Evans
DRPIII Steven Orth
DRSIII Jared Heck
Patricia Buckley Holly Harrington
Tammy Tomczak Hubert Bell
ROPreports Resource Guy Caputo
RidsSecyMailCenter Mona Williams
OCADistribution Allan Barker
Bill Borchardt James Lynch
Bruce Mallett Harral Logaras
Roy Zimmerman Viktoria Mitlyng
Belkys Sosa Prema Chandrathil
Nick Hilton Patricia Lougheed
Gerald Gulla Magdalena Gryglak
OEMAIL Resource
OEWEB
1