ML13071A242

Region II Comments on Finalized Panel Recommendations (Mab) Rev 2 12OCT2012

ML13071A242
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Site:	05523694
Issue date:	10/12/2012
From:	NRC/RGN-II
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55-23694-SP
Download: ML13071A242 (11)

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Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 1 of 11 I. General Considerations / Conclusions This response to the Review Panels conclusion is intended to show the NRR Program Office, the most accurate evaluation of the applicants performance. The following conclusions by Region IIs Exam Team are based on the observation of three examiners with extensive Industry and NRC experience. Region II considered the Review Panels Report in combination with the Exam Teams first hand observation of the applicants performance and applied the guidance of NUREG-1021 to provide the Program Office with an accurate evaluation that is defensible by the only three examiners that actually observed the applicants performance.

The Region II Exam Team concluded, with the opportunity of hindsight and deeper evaluation, that the initial evaluation as documented in the denial was largely accurate. The Region II Exam Team did, however, agree with some aspects of the Review Panels Report for assigning some errors to additional rating factors. Region IIs final conclusion is that the original denial should be sustained. Region IIs revised Form 303-1 can be found at the end of this document (Page 11 of 11).

II. Specific Review of Independent Review Panel Document Points A. Scenario 3, Event 5: A Main Turbine EHC Pump Trips

1. Original Grading: One non-critical error associated with Rating Factor (RF) 1.b, Interpretation/Diagnosis - Ensure Accuracy.

2. Independent Panel Recommendation: One non-critical error associated with RF 1.d, Interpretation/Diagnosis - Diagnose, and one non-critical error associated with RF 5.c, Directing Operations - Solicit Crew Feedback.

3. Region II Comments/Recommendations: Region II believes that the most appropriate grading of this event is to assign one non-critical error to RF 1.b. Discussion:

a. NUREG 1021 requires assigning the deficiencies to the RFs that most closely reflect the root cause of the error/deficiency.

b. The root cause of the error (incorrectly believing that the standby pump had failed to auto-start), was due to the applicant failing to collect all available information on which to base the diagnosis associated with the standby pump.

c. Post-exam follow up questions demonstrate that there was no error in understanding the operation of the EHC pumps. Furthermore, the

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 2 of 11 answers indicated that there was no deficiency in ability to make a correct diagnosis, given the appropriate information (asking the BOP for EHC pressures and trends). The applicant could also have verified that the HYD FLUID LO PRESS alarm (ALB20-D05) had NOT actuated. This alarm verification could easily have been performed without additional assistance from the board operators. In other words, she did not need to solicit crew feedback in order to interpret/diagnose, she only needed to collect the correct information that was readily available to her.

d. RF 5.c is more applicable to situations involving a whole team approach to operationally-oriented decision making. In this case, the operational decision had been made (correctly) to start the standby pump. Feedback from the crew was not required to make this decision.

e. RF 1.d. is not appropriate in this case, because as shown above the follow-up questions imply that the applicant would have made the appropriate diagnosis, if a complete set of parameters had been collected in order to make a more informed judgment.

B. Scenario 3, Event 7: Blocking Low Pressure SI/SLI during E-3

1. Original Grading: One non-critical error associated with RF 1.b, Interpretation/Diagnosis - Ensure Accuracy.

2. Independent Panel Recommendation: No error was assessed.

3. Region II Comments/Recommendations: Region II believes that the most appropriate grading of this event is to assign one non-critical error to RF 1.b. Discussion:

a. The applicant, as SRO, directed blocking the low pressure SI/SLI interlock without adequately collecting all pertinent information required to make a correct and accurate assessment that plant conditions would allow for this attempt to be successful.

b. Specifically, irrespective of what the procedure step directed, the licensed operator was expected to understand that the correct status of the interlock is given by the P-11 status lights, in conjunction with the associated pressurizer pressure instrument readings. The essential information required to correctly block the interlock was the condition of the interlock bistables, as shown by the P-11 status lights, no matter what the individual pressure instruments were reading.

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 3 of 11

c. The Review Panel states: This successful second attempt was considered a self correction by the Review Panel, which was key in the Review Panels determination. However, this statement is factually incorrect, in that the operators did NOT self correct their initial mis-operation; rather, the plant (simulator) failing to block SI/SLI was the source of correction. This situation is akin to another operator performing as a peer check and stopping a mis-operation from occurring. In this case, the plant (simulator) served, in essence, as the peer check to correct the erroneous initial mis-operation.

d. Appendix E of NUREG 1021 states that if you [an applicant] begin to make an error that is corrected by a peer checker, you will be held accountable for the consequences of the potential error without regard to mitigation by the crew.

C. Scenario 3, Event 4: Pressurizer Pressure Channel PT-455 Failed High

1. Original Grading: One non-critical error associated with RF 1.c, Interpretation/Diagnosis - Understanding.

2. Independent Panel Recommendation: One non-critical error associated with RF 1.c, Interpretation/Diagnosis - Understanding, one non-critical error associated with RF 2.c, Procedures - Correct Use, and one non-critical error associated with 5.b, Directing Operations - Oversight.

3. Region II Comments/Recommendations: Region II believes that the most appropriate grading of this event is to assign one non-critical error to RF 1.c, and an additional non-critical error to RF 5.d, Directing Operations -

Monitor Crew Activities. Discussion:

a. After displaying confusion over the status of the pressurizer pressure control system, the applicant (ultimately) did provide appropriate direction to the board operators. However, the root cause of the secondary error was that the applicant did not follow through and ensure that the board operators completed the operations as directed.

This error is more appropriately placed in RF 5.d, not RF 5.b.

b. Although the applicant did not initially follow the procedure correctly, the exam team believes the reason (root cause) of this failure was that the applicant was experiencing difficulties in understanding the correct status of the pressure control system at the time. Therefore, the exam team believes an error in RF 2.c may be inappropriate, or at most an error which only occurred as a result of a root cause weakness in RF 1.c.

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 4 of 11 D. Scenario 6, Event 4: Directing FIC-121 Back to Automatic (causing an unnecessary transient)

1. Original Grading: One non-critical error associated with RF 1.c, Interpretation/Diagnosis - Understanding.

2. Independent Panel Recommendation: One non-critical error associated with RF 1.c, Interpretation/Diagnosis - Understanding, and one non-critical error associated with RF 5.b, Directing Operations - Solicit Crew Feedback.

3. Region II Comments/Recommendations: Region II agrees with the Review Panels overall assessment of this error and their grading.

E. Scenario 7, Event 1: Tave trended low over time, and ultimately went low-out-of-band.

1. Original Grading: One non-critical error associated with RF 3.a, Control Board Operations - Locate & Manipulate.

2. Independent Panel Recommendation: No errors were assessed for this event.

3. Region II Comments/Recommendations: Region II believes that the most appropriate grading of this event is to assign one non-critical error to RF 3.a.

Discussion:

a. Examiner notes were very thorough in documenting communications between members of the applicants operating crew. With this in mind, no documentation within those examiner notes indicate any communication between crew members with respect to Tave trends for over 40 minutes.

b. The crew members submitted signed statements that suggested that the applicant was providing frequent updates on temperature trend. The crew members were constructing these statements approximately two months after administration of the scenarios based solely on memory and without notes. It can easily be seen that the crew members statements are inaccurate by inspecting the examiner notes related to the RWST Sludge Mixing Leak and comparing them to the signed statements submitted by the crew members.

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 5 of 11

c. OLMC-500 states that when there is a disagreement of facts between the examiners and the applicants, the examiners facts are to be used.

d. The applicant withdrew control rods at approximately 07:36:50.

Approximately, 20 minutes later P. Capehart and M. Bates held a conversation in the back of the simulator regarding the applicants lack of monitoring the primary plant. It was obvious to the examiner that the applicant was not actively monitoring plant parameters. P. Capehart also recognized that the applicant was not monitoring trends on the IPC computer.

e. Tave exited and remained outside of the directed control band of 2oF, for almost 5 minutes before the applicant noted Tave being outside of the control band.

f. RF 3.a is appropriate for this error because the applicant failed to manipulate control rods in a timely manner to maintain the Tave/Tref band as directed by the SRO. The untimely control rod operation reflects the applicants competency because she was provided ample opportunity to monitor Tave and operate rods to maintain the directed band. Over this >40 minute period, the applicant did not actively monitor control boards, which prompted a conversation between two NRC examiners about the apparent lack of monitoring. The challenges provided by scenario design were minimal to the extent that it should not have impacted her ability to monitor, operate control rods, or request a larger control band for Tave.

F. Scenario 7, Event 6: RWST Sludge Mixing Line Pipe Break with Failure to Automatically Isolate

1. Original Grading: One non-critical error associated with RF 3.a, Control Board Operations - Locate & Manipulate.

2. Independent Panel Recommendation: No errors were assessed for this event.

3. Region II Comments/Recommendations: Region II believes that the most appropriate grading of this event is to assign one non-critical error to RF 3.a.

Discussion:

a. The examiners believe this to be a very significant error that unequivocally speaks to the applicants competence with respect to locating equipment.

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 6 of 11

b. It is irrelevant that the applicant was assigned to monitor the reactor because the primary plant was stable during this entire event; which provided the applicant ample opportunity to be cognizant of the event and provide assistance to the extent that it did not impact her ability to monitor a stable reactor.

c. The applicant was involved in documented conversations with the Unit Operator (UO) with respect to the fact that RWST Sludge Mixing Valves should have closed on LOW RWST LEVEL.

d. The Review Panel suggests that because no items on the ES-D-2 Forms specifically state that the applicant was required to provide assistance, then it is not appropriate to downgrade her performance in this area.

Region II believes that it is entirely appropriate to downgrade performance when an applicant displays weakness in any one of the rating factors when given a fair opportunity to display competence. ES-D-2 Forms are created during exam development as a means to credit a specific position for performance of verifiable actions, but do not contain every possible attribute that could possibly be evaluated for the crew members. Simply because an event is credited for one position does not mean that competency weaknesses cannot be observed in the other applicants (serving in other positions). Form ES-D-2 was not required to be modified after the scenario because the actions were largely carried out as prescribed. It was the timeliness of those listed actions (locating handswitches) that constituted the basis for all operators on the crew to have their performance downgraded.

G. Scenario 7, Event 3: Loss of Cooling to Letdown Heat Exchanger (TE-130 Fails Low)

1. Original Grading: One non-critical error associated with RF 3.c, Control Board Operations - Manual Control.

2. Independent Panel Recommendation: One non-critical error associated with RF 1.c, Interpretation/Diagnosis - Understanding, and one non-critical error associated with RF 3.c, Control Board Operations - Manual Control.

3. Region II Comments/Recommendations: Region II believes that the most appropriate grading of this event is to assign one non-critical error to RF 3.c and a second non-critical error associated with 3.b, Control Board Operations - Understanding. Discussion:

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 7 of 11

a. Both the Review Panel and Region II agree that RF 3.c is appropriate, therefore the remaining discussion will focus on the understanding attribute.

b. Both the Review Panel and Region II agree that the applicant displayed a weakness in her understanding. The Review Panel believes that this understanding issue should be assigned to RF 1.c, Interpretation/Diagnosis - Understanding. Region II believes that the understanding issue is required, iaw NUREG-1021, to be assigned to RF 3.b, Control Board Operations - Understanding.

c. Form ES 303-4 states that Competency 1 is associated with directives and actions. Therefore, to meet the logical nature of this statement, errors in this RF must be related to both aspects.

d. Also on Form ES 303-4, RF 3.b. is related to the applicants control manipulations (i.e., actions) with respect to understanding. The difference between RF 1.c and RF 3.b. is the position the applicant is holding when the error is committed (SRO vs. RO/BOP).

e. This is supported by the fact that RO competency forms do not contain a RF for understanding under competency 1 (all errors associated with understanding would be placed in competency 3).

f. This is further supported by the fact that SRO-upgrades who do not fill a position on the control boards are rated as not observed for competency 3 (all errors associated with understanding would be placed in competency 1).

e. NUREG-1021, Appendix D also supports this methodology of differentiation between the two rating factors. (p. 17 of 29 in App. D)

f. We agree with the Review Panel that an understanding error was made; therefore, in accordance with NUREG 1021, the correct assignment of the understanding error is RF 3.b.

H. Scenario 6, Event 4: Controlling Pressurizer Level Transmitter (LT-459) Failed Low

1. Original Grading: Two non-critical errors associated with RF 4.a, Communications - Clarity.

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 8 of 11

2. Independent Panel Recommendation: One non-critical error associated with 4.a, Communications - Clarity.

3. Region II Comments/Recommendations: Two non-critical errors associated with RF 4.a, Communications - Clarity. Discussion:

a. Both the Review Panel and Region II agree with the error associated with communication of the status of FIC-121; therefore, the following discussion will be limited to the applicant incorrectly directing Immediate Operator Actions (IOAs) when procedures do not contain any IOAs for this malfunction.

b. The applicant directed IAOs to be performed, when no IAOs existed for the malfunction. The examiners had to make a determination as to the root cause of this error - interpretation/diagnosis?, procedure reference?,

or simply communication/clarity? During the examiners post-scenario caucus, it was clear that the applicant made an error in that she incorrectly directed IOAs. The exam team determined that follow-up questions needed to be asked in order to determine whether she initially had a diagnosis problem, a procedure reference problem, or a communication problem. The applicant stated that she had misspoke.

The applicant admitted that her communication was not correct and in doing so, she provided the necessary information needed to assign the error to RF 4.a.

c. The Review Panel does not provide any justification in their report for discarding this error. The Review Panel forces the reader to try to deduce their reasoning for this error by reading their justification of why they retained the FIC-121 error. It can only be assumed that the Review Panel has made their determination based on the communication error not hindering procedure entry or performance. Region II would like to point out that this justification appears to be hinged solely on the lack of consequences for this particular error. Region II would also like to point out that the Review Panel, in their Report, had repeatedly stated that an applicants performance is not evaluated based on consequences. This appears to be (1) an inconsistent application of standards by the Review Panel, and (2) an incorrect determination in accordance with NUREG-1021 guidance.

d. The exam team believes strongly that this is not only a communication error, but it is a communication error that speaks to the applicants competency in her ability to communicate. Although NUREG-1021 clearly states that errors are not evaluated on consequences, this error

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 9 of 11 although not having consequences during the scenario, due to strong performance of the ROs, has significant potential consequences.

Directing IOAs when none exist has the potential to introduce uncertainty with respect to the ROs diagnosis. When an SRO tells ROs to perform actions that either make no sense, or are not directed by procedure, the ROs may question whether they have diagnosed the malfunction correctly and then question which actions may be needed to mitigate the malfunction.

I. Scenario 3, Event 1: Steam Generator (SG) #4 NR LT-554 Failed High; Scenario 3, Event 4: Controlling Pressurizer Pressure Channel PT-455 Failed High

1. Original Grading: Two non-critical errors associated with RF 4.b, Communications - Crew & Others Informed.

2. Independent Panel Recommendation: Two non-critical errors associated with RF 4.b, Communications - Crew & Others Informed.

3. Region II Comments/Recommendations: Two non-critical errors associated with RF 4.b, Communications - Crew & Others Informed. Discussion:

a. Both the Review Panel and Region II agree with two non-critical errors associated with RF 4.b, Communications - Crew & Others Informed; therefore, no further discussion is necessary.

J. Scenario 6, Event 1: ACCW Pump 31 Locked Rotor with Failure of the Standby ACCW Pump to Automatically Start

1. Original Grading: One non-critical error associated with RF 4.c, Communications - Receive Information.

2. Independent Panel Recommendation: One non-critical error associated with RF 4.c, Communications - Receive Information.

3. Region II Comments/Recommendations: One non-critical error associated with RF 4.c, Communications - Receive Information. Discussion:

a. Both the Review Panel and Region II agree with one non-critical error associated with RF 4.c, Communications - Receive Information, therefore, no further discussion is necessary.

K. Scenario 7, Event 7: MFRV #3 Failed Shut Requiring Reactor Trip, Three Stuck Rods

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 10 of 11

1. Original Grading: One non-critical error associated with 4.a, Communications - Clarity.

2. Independent Panel Recommendation: One non-critical error associated with 4.a, Communications - Clarity.

3. Region II Comments/Recommendations: One non-critical error associated with 4.a, Communications - Clarity. Discussion:

a. Both the Review Panel and Region II agree with one non-critical error associated with RF 4.a, Communications - Clarity, therefore, no further discussion is necessary.

Region II Recommendations/Comments on the Final Independent Review Panel Document, October 12, 2012 Page 11 of 11 REGION II RECOMMENDATIONS (as of 10/12/12)

Senior Reactor Operator Simulator Operating Test Grading Details Competencies/

Rating Factors (RFs)

RF Weights RF Scores RF Grades Comp.

Grades Comment Page No.

1.

Interpretation/Diagnosis

a.

Recognize & Attend

b.

Ensure Accuracy

c.

Understanding

d.

Diagnose 0.20 0.20 0.30 0.30 3

1 1

2 0.60 0.20 0.30 0.60 1.70 EHC, SI/SLI PHtr, FIC121 CR Auto Op

2.

Procedures

a.

Reference

b.

EOP Entry

c.

Correct Use 0.30 0.30 0.40 3

3 3

0.90 0.90 1.20 3.00

3.

Control Board Operations

a.

Locate & Manipulate

b.

Understanding

c.

Manual Control 0.34 0.33 0.33 1

2 2

0.34 0.66 0.66 1.66 PORVCT, Tave, RWST TE130 TE130

4.

Communications

a.

Clarity

b.

Crew & Others Informed

c.

Receive Information 0.40 0.40 0.20 1

1 2

0.40 0.40 0.40 1.20 F121, IOA, SI #s SM, SM ACCW 3-way

5. Directing Operations

a.

Timely & Decisive Action

b.

Oversight

c.

Solicit Crew Feedback

d.

Monitor Crew Activities 0.30 0.30 0.20 0.20 3

2 3

2 0.90 0.60 0.60 0.40 2.50 FIC-121 to auto PZR Htrs F/U

6. Technical Specifications

a.

Recognize and Locate

b.

Compliance 0.40 0.60 1

3 0.40 1.80 2.20 3 errors (not contested)

[Note:

Enter RF Weights (nominal, adjusted, or 0 if not observed (N/O)), RF Scores (1, 2, 3, or N/O), and RF Grades from Form ES-303-4 and sum to obtain Competency Grades.]