ML17157B090
| ML17157B090 | |
| Person / Time | |
|---|---|
| Site: | Susquehanna  |
| Issue date: | 03/11/1992 |
| From: | Conte R, Walker T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17157B087 | List: |
| References | |
| 50-387-92-10-MM, 50-388-92-10, NUDOCS 9203190099 | |
| Download: ML17157B090 (74) | |
See also: IR 05000387/1992010
Text
U. S. NUCLEAR REGULATORY COMMISSION
REGION I
REPORT NOS.:
DOCKET NOS.:
50-387/92-10
50-388/92-10
50-387
50-388
LICENSE NOS.:
NPF-22
LICENSEE:
Pennsylvania Power and Light Company
2 North Ninth Street
Allentown, Pennsylvania
18101
FACILITY'EETINGAT'usquehanna
Steam Electric Station
Region I Office, King of Prussia, Pennsylvania
MEETING CONDUCTED: February 14, 1992
Submitted by:
T. Walk, Senior Operations Engineer
BWR Section, Operations Branch
Division of Reactor Safety
Date
Approved By:
Richard J. Con, Chief
BWR Section, Operations Branch
Division of Reactor Safety
J)
Pm
ate
Summary:
A meeting was held at the licensee's
request on February 14, 1992, to discuss the
licensee's actions in response
to weaknesses
identified during the Licensed Operator
Requalifiication (LOR) program evaluation performed in January
1992.
The licensee
presented
the results of the root cause analysis performed by their Event Review Team
(ERT) ~
They also described their response plan for correction of the identified weaknesses
in the LOR program.
The root cause analysis was thorough and comprehensive
and the
corrective actions adequately address
the identified weaknesses.
DETAIL/
1.0
Lntnr duct~in
On February 14, 1992, at the NRC Region I Office, the below listed personnel
participated in a meeting to discuss Pennsylvania Power and Light's (PP&L's) actions
in response to weaknesses
identified during the LOR program evaluation conducted by
the NRC in January
1992.
2.2 M~i<<d
2.1
Penns
lvania Power & Li ht Com an
H. G. Stanley, Superintendent of Plant - SSES
H. J. Palmer, Manager - Nuclear Operations
T. R. Markowski, Day Shift Supervisor
W. H. Lowthert, Manager - Nuclear Training
A. S. Fitch, Operations Training Supervisor
J. Kenney, Licensing Group Supervisor
R. M. Peal, Supervisor - Nuclear Compliance
H. Lloyd, Compliance Evaluator
G. Jones, Manager - Nuclear Engineering
H. Woodeshick, Special Assistant to the President
2.2
~her
R. Janati, PA DER/BRP
D. Ney, PA DER/BRP
J. Henrich, International Representative
- IBEW
E. Fox, Local 1600 - IBEW
2.3
Nuclear Re ulato
mmi
i n
M. W. Hodges, Director, Division of Reactor Safety (DRS)
L. H. Bettenhausen,
Chief, Operations Branch (OB), DRS
J. White, Chief, Reactor Projects Section 2A, Projects Branch 2,
Division of Reactor Projects (DRP)
T. E. Walker, Senior Operations Engineer, OB, DRS
S. Barber, Senior Resident Inspector, Susquehanna,
J. Raleigh, Project Manager, Office of Nuclear Reactor Regulation
3
3.0
Licen ee Pr
entati
n
The Superintendent of Plant - SSES explained the purpose of the meeting.
The
Manager - Nuclear Operations discussed
the history of the LOR program leading up
to the program evaluation conducted in January
1992.
He explained the actions taken
in response to the identified deficiencies and discussed
the results of the root cause
analysis.
He also introduced the Evaluation and Response
Plan that PP&L has
developed to identify and correct the weaknesses
in their LOR program.
His
presentation is included as Attachment 1.
The Event Review Team Root Cause
Analysis is included as Attachment 2.
The Manager - Nuclear Training presented
the details of the Evaluation and Response
Plan and discussed
the status of the corrective actions.
His presentation
is included as
Attachment 3.
The Evaluation and Response
Plan is included as Attachment 4.
4.0
Qgn~cl i~in
The root cause analysis appears to have been thorough and comprehensive in
identifying the causes of the weaknesses
in the requalification program.
The
conclusion that PP&L lost focus on superior operator performance and accepted
performance that should have been rejected during normal training and evaluation was
insightful. The corrective actions described in the Evaluation and Response
Plan
adequately address the identified root causes and causal factors and should prevent
recurrence of the problems.
PENNSYLVAI.'GAPOWER AI%3 LIGHT COMPAXED
SUSQUEHAN'M STEAM ELECTRIC STATION
LICENSED OPERATOR REQVALIFICATION
PROBLEM STATEMENT
HOWAIG) J. PALMER, JR - SRO
MANAGER- NUCLEAR OPERATIONS
HOW WE GOT HERE
PROCESS FOCUS INSTEAD OF PERFORI'NANCE FOCUS
WHERE WE AjRE NOW
PROPER EXAMS ARE BEING CONDUCTED
OPERATORS A)RE COMPETENT Al%) FULLYQUALIFIED
WHERE WE ARE GOING
EVALUATIONA2'6) RESPONSE PLAN
LEADINGTO
FLAWLESS PERFORMiANCE
HOW WE GOT HERE
19SO
19S6
1987
19S9
1990
THE DENTON LETTER (1 1/2 PAGES)
10CFR CHANGE
ES601, REV. 4 (14 PAGES)
ES601, REV. 5 (79 PAGES)
ES601, 602, 603, 604, 605, REV. 6 (121 PAGES)
PRIOR TO 1992, 543 EXAMS, 24 PARTIALFAILUIRES
NRC PAIW.LLELGRADING
19S9
1990
1991
16, ONE RO,
20, TWO RO,
20,
DRAFT
REV. 5
100%
REV. 5
100%
REV. 6
100%
1992
12~ ONE SRO, 2 RO, 1 TEAM REV. 6
100%
PPdkL
1992
40, 2 RO TO DATE
26, TO GO
PROCESS FOCUS
MMARC/MAlVl"G/BWROG/NRCMEETINGS
TRAINIINGON TEST CONDUCT
TEST MATERIALDEVELOPMENT
REV. 5
REV. 6
JPMS/QUESTIONS
75
10/YR (125-150)
LIMITSAND CONTROLS
350
75/YR
STATIC SIIVHJLATOR
SIMULATOR SCENARIOS
350
75/YR
5/YR (30)
NUIREG 1021 "EXPERTS"
ISCT LAWYERS REV 5/6
SAVE THE PROGRAM
FATALFLAW
GOOD
EVAL
BAD
ISCTS VS. COMPETENCIES
WjHERE WE ARE NOW
JAI%7ARY 6 - 9
NRC EXAMS/STOPPED SIlVHjLATOR
EXAMS
JANUARY 13
MEETINGWITHSHIFT SUPERVISORS
SIMULATORINSTRUCTORS
JANUARY 15
MANAGER- NVCLEAROPERATIONS
PERSONI&L ASSESSMENT PROVIDED
TO THE PLANT SUPEM1%TENDENT
JANUARY 13 - 23
ERT/ROOT CAUSE
JANUARY 17
MEETING WITHJOHN KAUFFMANTO
REVIEW RESPONSE PLAN
JAZ'AJARY 24
EVALUATIONTRAINIING
JAIAJARY2S
RECOMMENCED SIIVHJLATOREXAMS
FEBRUARY 6 - 7
COMBIMD SHIFT SUPERVISOR A2'G)
SIIVHjLATORINSTRUCTOR MEETING
FEBRUARY 14
KmG OF PRUSSIA
ROOT CAUSE RESULTS
12 TEAMMEMBERS
3 PROBLEM STATEMENTS
TIMELINE
20 INTERVIEWS
ANALYSIS
ROOT CAUSES
CAUSALFACTORS
12 RECOMMENDATIONS
CAUSES
RO T CAUSES
EVALUATORS
LACKEDFORMAL GUjlBANCE
PLACED EMPHASIS ON RECOVERY VICE
INAPPROPRIATE ACTION
DID NOT CONSIDER WHAT COULD HAVEHAPPENED
INADEQUATEPERIODIC ASSESSMENT OF OUR PROGRAM
COMPARED TO CUIRENT STANDARDS
AUSALFACTORS
EVALUATORS
BOTH SCENARIOS INSTEAD OF ONE
CRITICALS'j.'EPS ONLY, DID NOT INCLUDE
COMPETENCY
NOT FORMALLYTRAINED
TECKACALSIGNH. ICANCE, COLD WATER WITHTWO
RODS OUT
PROCEDURES
EOPS DO NOT REFLECT EPG REV. 4
CAUSES
CONTINUED
EXTERNALFA T R
"CRASH/BUKN"SCENARIOS
IMPORTANCE OF ISCTS
LOWER RISK BEHAVIOR
SELF/TEAM LOOK BAD DUE TO QUESTIONS
TAKINOTHERS'CSTS
STRESS
EXTRA OBSERVERS
CAREER IMPLICATIONS/PRESSURES
UNKNOWNEVALUATORSTAI%3ARDS
POTENTIALFOR A THIRD SCENARIO
RECOINIVK<NDATIONS
ADDITIONAL
COINIVKMCATIONS
TEAMWORK
FUNDAMENTALOPEIUTIONS
PAIMVKTERCONTROL
PROCEDURES
USAGE DURII'%G TRANSIENTS
EQUIPMENT RESTORATION
IMPLEMENTEOP EPG REV. 4
EVALUATORS
SCENARIO DEVIATIONS
PERFORMANCE NOT JUST ISCTS
INSTRUCTORS/SUPERVISION
OPERATING EXCELLENCE
CONSISTENT DIRECTION
COMMUNICATERESULTS
LICENSED OPERATORS
1VRMAGEMENT
WHERE WE AjkE GOING
EVALUATIONue) RESPONSE PLAN
LEADINGTO
FLAWLESS PERFORMANCE
LIVINGDOCUMENT THATWILLBE UPDATED TO INCLVDE
ALLLESSONS LEARj.'WDDtjRINGJANUARYAND
FEBRUARY TO SET OUR NEW DIRECTION IN LICENSED
OPERATOR TRAININGAND EVALUATION.
I
LICENSED OPERATOR REQVAL
EXP'VENT
REVIEW TEAMREP
TABLE OF CONTENTS
Page
Executive
Summary
II.
Introduction
III. Background
IV.
Analysis Techniques/Root
Cause Analysis
V.
Interview Summary
13
VII. Recommendations/Actions
to Prevent Recurrences
16
Attachments
A.
B.
C.
D.
Historical Requal Timeline
Cause
and Effect Chart
Team Failure
Cause
and Effect Chart
RO Failure/Associated
Timeline
Cause
and Effect Charts
D.1
SRO Failure
(PP&L/NRC Disagree)
D.2
Team Failure
(PP&L/NRC Disagree)
E.
Cause
and Effect Symbols Legend
January
23,
1992
Page
1 of 17
EXECUTIVE 8UMMARY
During the week of January
6,
1992, the
NRC participated in the
Licensed Operator Requalification
exams at
SSES.
While the
NRC
evaluated
our Requalification Program
as satisfactory,
there were
several
problems that could easily have resulted in our program
being rated unsatisfactory.
This could have resulted in severe
ramifications for PP&L.
The problems were:
~
Three of 12 operators failed the simulator exam.
~
One of three operating
teams failed the simulator
exams.
~
PP&L evaluators initially passed
individuals and
a team
that the
NRC failed.
Our analysis of this event identified several
causes
as described
in the root cause analysis.
The key item is that
PP&L lost focus
on superior operator
performance
as the path to exam success.
In
our normal training and evaluation
we accepted
performance that
we should have rejected.
We will re-establish
our performance
standards
and implement
training to meet them.
We will train our evaluators to focus
on performance.
We will help our operators
understand that the path to exam
success
is the
same
as the path to flawless operation every day.
We believe the recommendations
identified by this analysis will
correct the underlying problems
and restore
our operation to the
performance
levels that
PP&L demands.
January
23,
1992
Page
2 of 17
INTRODUCTION
During the week of January.
6,
1992, the
NRC performed their
annual Licensed Operator Requalification
exam and inspection at
Susquehanna
SES.
The purpose of their visit was to perform
requalification examinations
on a selected
group of licensed
operators
and to evaluate
our Licensed Operator Requalification
Program.
Twelve licensed operators
were scheduled for examination:
1
SRO from Operations
(Unit Supervisor)
5
SROs from Training (Simulator Instructors)
6 ROs from Operations
(PCOs)
PP&L evaluators
were:
Manager
Nuclear Operations
primary management
contact
Day Shift Supervisor
team evaluator,
SRO evaluator
Operations Training Supervisor
SRO evaluator
Shift Supervisor/Procedures
RO evaluator
Unit Supervisor
RO evaluator
At the conclusion of the week,
one
SRO,
two ROs,
and one team
failed the simulator portion of the
exam.
In addition,
evaluators
and
NRC evaluators did not initially agree
on any of
the failures but agreement
was reached
before the exit meeting.
These results
allowed the
NRC to ultimately find our
Requalification Program acceptable.
One more individual failure,
one more team failure, or failure to reach
agreement with the
NRC
on our final evaluations,
would have meant our Requalification
Program would have been found unacceptable.
An unacceptable
Licensed Operator Requalification Program has severe
ramifications for the company.
As a result,
a team of
individuals was assembled
to perform a Root Cause Analysis on the
problems that occurred during the week of January
6,
1992.
January
23,
1992
Page
3 of 17
BACKGROUND
Annually, all licensed operators
are given requalification
examinations.
The examination consists of three parts:
Written exam
Plant walkthroughs
(JPMs)
Simulator
exam
All operators
are evaluated
by a team of PP&L management
individuals.
In addition,
a selected
group is also evaluated
by
a team of individuals from the
NRC.
Each operator
must be
evaluated. at least
once every six years
by the
NRC.
The existing
process
has
been in place at PP&L since our 1989 annual
exams.
For the simulator portion of the exam, the individuals are
assembled
into four man teams.
One
SRO is designated
Shift Supervisor
One
SRO is designated
Unit Supervisor
One
RO is designated
PCO-U (Unit)
One
RO is designated
PCO-X (Extra)
Each team is also provided with an STA.
The team is then given two transients/accident
scenarios
to
combat.
A third scenario
may be required depending
on
performance in the first two.
Each licensed operator is
evaluated
on his individual performance
and the team is evaluated
on overall performance.
To aid in the evaluation,
individual
simulator critical tasks
have
been developed for both individual
operators
and team performance
on tasks that have
a plant or
public safety significance.
It is intended that these "critical
tasks"
be objective measures
by which NRC and
PP&L evaluators
can
determine whether
an operator or team's
performance is
satisfactory.
Each individual should be exposed to at least
one critical task
per scenario.
Failure of a team to perform all critical tasks
results in team failure and at least
one individual failure; the
individual who was expected to perform the critical task.
Performance of an individual's critical tasks
by others
on the
team is allowed as long as
each individual performs at least
one
critical task per scenario set.
If any individual does not
perform a critical task in both scenarios,
there are two options:
Option
1
backfit a critical task
Option
2
perform a third scenario
January
23,
1992
Page
4 of 17
ANALYSIS TECHNI UES
The Event
H.A.J.
L.D.
R.M.
D.F.
Review Team
Lloyd
Dominguez
O'eil
Peal
Roth
was comprised of the following individuals:
Compliance Evaluator
(Team Facilitator)
NSAG Site Supervisor
Project Manager
Supervisor
Nuclear Compliance
PNSS
Systems
Engineering Supervisor
J.M.
A.S.
W.H.
T.R.
H. J.
D.J.
B.R.
Boiwka
Fitch
Lowthert
Markowski
Palmer
Steffenauer
Stitt
- Plant Control Operator
Operations Training Supervisor
Manager
Nuclear Training
Day Shift Supervisor
-'anager
Nuclear Operations
Shift Supervisor
Simulator Instructor
To perform a Root Cause Analysis on the events that occurred
during the week of January
6,
1992, the team developed three
problem statements
to be analyzed.
Problem Statements
1.
Team 1,
an
SRO and an
RO, failed scenario
1 during their
evaluation.
Scenario title:
Loss of RPS,
Loss of 125
VDC,
MSIV Isolation.
2.
An RO on Team
2 failed during their scenario
1.
Scenario
title:
Startup at 204 Power with a Main Transformer Fire
and
ATWS.
3.
PP&L and
NRC evaluators did not initially agree
on these
results for problems
1 and 2.
Data for the analysis
was gathered
by the following means:
Interviews with licensed personnel
Discussions with evaluators
(PP&L)
Document review
Scenarios
Examiner's
standards
Industry experience with exam process
January
23,
1992
Page
5 of 17
The Event Review Team then constructed
a timeline of the history
of the
NRC monitored requalification exams,
including SSES
exam
history.
The cause
and effect technique
was utilized for analysis of each
problem statement.
Following the initial analysis,
a review
meeting was held with the operating
crews for problems
1 and
2
and with the evaluators for problem 3.
The interview process
consisted 'of two phases.
Phase
one was for
interview information necessary
for performance of root cause
analysis.
Phase
two involved a formal interview process
of a
larger sample of operations
personnel
and provided valuable
feedback to assess,
in addition to the root cause analysis.
Refer to attachments
A D.2 for timelines, individual event
and
causal factor charts,
and interview summary.
Attachment
E
provides
a symbols
legend which was specifically tailored for
this analysis.
This symbols legend
was developed
since the
programmatic evaluation varied somewhat
from typical plant event
evaluations
which use standard
symbols.
January
23,
1992
Page
6 of 17
Problem
1
Problem statement:
Team 1,
a
SRO and
a RO, failed scenario
1 during their
simulator evaluation.
'imeline/scenario
description:
~
Initial conditions
804 power.
~
During a HPCI surveillance,
a steam supply valve is
shut and will not re-open.
Operators
recognized that
HPCI was inoperable
as expected.
The 'B'PS
bus was de-energized
and an outboard
went shut simultaneously.
Operators
responded
to the
loss of RPS, detected
the MSIV valve closure,
and
stabilized the plant as expected.
~
Before the
RPS isolation was reset,
1D622
(125
VDC bus)
was lost, resulting in full MSIV isolation and
a scram.
The loss of 125
VDC also prevents the 'B'uxiliary bus
transfer
and disables
a
CRD pump.
Two rods fail to
insert.
The crew is expected to control reactor vessel level
and pressure
with only RCIC,
one
CRD pump,
and
available.
The crew's response
was good, initially,
recovering
RCIC and working to restore
DC power.
But
the Unit Supervisor did not realize that feedwater
was
not in start-up level control and the
PCO misled him.
This resulted in an uncontrolled level increase to
about
80 inches.
The Unit Supervisor,
the
PCO,
and the
team failed due to uncontrolled condensate
injection
into a non-shutdown reactor.
The cause
and effect analysis is attached.
Root causes
identified were:
Less than adequate
communications
by the team.
Less than adequate
level monitoring by the team.
Note:
Problem
2 indicates
lack of teamwork as
a
root cause.
This is implied by the numerous
communication concerns for this problem,
even
though not directly concluded
by the cause
and effect process.
January
23,
1992
Page
7 of 17
Problem
2
Problem statement:
A RO on Team
2 failed scenario
1 during his simulator
evaluation.
Timeline/scenario description:
The scenario
begins at 204 power during start-up.
The crew
transferred auxiliary busses
to the generator
and placed
feedwater in three-element
control without incident.
The power supply to division
1
SRV acoustic monitors failed
and the team entered the expected
LCOs and started repair
efforts.
A winding short in main transformer
1A caused
and transformer fire, and while the crew responded
to this
scrammed
causing
a hydraulic ATWS.
The
crew responded initially by stabilizing level and pressure
and started to work on getting rods in.
Because
level control was in automatic
(3 element)
at about
8% power, level began to swing and reached
54" (feed
pump
trip) prior to taking control of feedwater.
Level dropped while the
PCO tried to recover
a feed pump.
The
PCO assured
the
US that he'd recover the feed
pump
several times, but HPCI. and RCIC started automatically
on
low level before the feed
pump was available.
The
PCO failed due to failure to control vessel level during
an
ATWS event.
He did not recover feedwater which resulted
in auto initiation of HPCI and RCIC.
The cause
and effect analysis is attached.
Root causes
identified were:
Lack of level control by the
PCO.
Less than adequate
communications
from the
PCO to the
US 'and from the team to the
PCO.
Less than adequate
monitoring/responding/controlling
vessel level by PCO and team.
January
23,
1992
Page
8 of 17
Problem
3
Problem statement:
PP&L and
NRC evaluators did not agree initially on the exam
failures.
Timeline/scenario description:
The scenario timelines were given in problems
1 and
2 and
need not be repeated.
The grading timeline is as follows:
~
After each simulator exam,
PP&L informed the
NRC
of our preliminary grades.
This occurred three
times:
Monday, 1/6, approximately
12:00 p.m.
Monday, 1/6, approximately 5:00 p.m.
Tuesday,
1/7, approximately
12:00 p.m.
All of these preliminary grades,
team and
individual, were passes.
~
On Tuesday afternoon,
1/7, the
NRC informed PP&L of
their grading on simulator exams.
Their grades
included three individual failures and one team
failure.
~
On Wednesday
morning, 1/8,
PP&L evaluators
discussed
the results
and changed their grading to agree with the
NRC on the team failure and both
PCO failures.
We
decided to discuss the
SRO failure with them again.
~
On Wednesday
afternoon,
the PF&L exam team discussed
the results with the
NRC again.
The
NRC maintained
their stance
on failing the
SRO.
~
On Thursday,
1/9,
PP&L gave their official grades to
the
NRC.
Our final stance
agreed with the
NRC
completely, failing three individuals and one team.
Two cause
and effect analyses
are attached.
The team developed
one cause
and effect analysis for the disagreement
on team
grading and one for the disagreement
on individual grading.
This
was done because
the subject
became too complicated to use only
one cause
and effect analysis effectively.
January
23,
1992
Page
9 of 17
Note:
The recommended
actions to prevent recurrence for this
problem statement
addresses
both root causes
and causal
factors.
The root cause:
"Our evaluation standard is
not defined" and its proposed solution will eliminate
those causal factors which do not have specific
solutions.
Root causes
identified were:
~
PP&L evaluators
lacked formal guidance
on the
evaluation process.
~
PP&L evaluators
placed
more emphasis
on recovery
actions than on the inappropriate action itself.
~
PP&L has
no formal mechanism to maintain awareness
of
industry expectations.
Therefore,
yearly assessments
of our program,
compared to new regulatory issues
and
current industry experience,
is not always complete.
~
PP&L evaluators
did not employ a "what could have
happened
approach"
but rather the actual
consequences.
Causal factors identified were:
PP&L emergency operating procedures
do not reflect rev.
4 of the
PP&L made their decision
based
on both scenarios
where
NRC based theirs on only one scenario.
PP&L evaluated
based
on critical steps only, where the
NRC evaluated
based
on performance,
as well as critical
steps.
PP&L evaluators
are not formally trained
on requal
evaluations.
PP&L evaluators did not consider the technical
significance of cold water injection with two control
rods not inserted.
Operators belief that there is a lower risk behavior
during examination to reduce the potential of:
Self or team looking bad due to questions
Taking others'ritical steps
January
23,
1992
Page
10 of 17
Several external factors-were identified.
While external factors
may not be totally resolvable,
they are worth noting:
Stress level during the
exam
Extra observers
in simulator
Career implications/pressures
Unknown evaluator standards
Potential for a third scenario
Importance of individual critical steps
Emphasis
on "crash/burn" scenarios
versus
expected
January
23,
1992
Page
11 of 17
ROOT CAUSE
SUMMARY
Problem Statement
1
Less than adequate
communications
by the team.
Less than adequate
level monitoring by the team.
Problem Statement
2
Lack of level control by the
PCO and the team.
Less than adequate
communications
from the
PCO to the
US and from the team to the
PCO.
Less than adequate
monitoring/responding/controlling
vessel level by
PCO and team.
Problem Statement
3
PP&L evaluators
lacked formal guidance
on the
evaluation process.
PP&L evaluators
placed
more emphasis
on recovery
actions than on the inappropriate action itself.
PP&L has
no formal mechanism to maintain awareness
of
industry expectations.
Therefore, yearly assessments
of our program,
compared to new regulatory issues
and
current industry experience,
is not always complete.
PP&L evaluators did not employ a "what could have
happened
approach"
but rather the actual consequences.
January
23,
1992
Page
12 of 17
REQUAL ERT
INTERVIEW 8%SCARY
INTERVIEW SAMPLE
Shift Supervisors:
Unit Supervisors:
Assistant Unit Supervisors:
Plant Control Operators:
Simulator Instructors:
2
2
1
10
5
Total:
20
Total Number of Licensed Operators
73
January
23,
1992
Page
13 of 17
REQUAL ERT
UESTIONNAIRE SUMMARY
SIMULATOR ONLY
1.
How do you feel about the requal
exam process?
~
A lot of stress.
~
It's not a true test of operators'bilities.
The time
being seen during the
exam
(two hours simulation)
does
not truly reflect the operator's ability.
~
The simulator scenarios
are too ambiguous to grade.
They are subject to the examiner's interpretation.
~
Rules change,
always something
new year to year
(supposedly
enhancements).
la.
Has it changed
over the past several
years?
Yes
16
No 2
1b.
How?
2 ~
3 ~
~
Emphasis
has
changed
as to what is successful.
~
Changing rules just prior to exam.
~
Don't know the rules
now.
How did you
(do you) feel going into this particular
exam?
~
Nervous.
~
Don't know what to expect.
In your words what is a critical step?
Something that, if not performed correctly, could
adversely affect plant operation
and safety of public.
Something that will pass or fail an individual (for an
exam) .
January
23,
1992
Page
14 of 17
3a.
Do critical steps
influence your performance during an
exam?
Yes
11
No-8
~
Don't want to take someone's critical step.
If you do,
you get another scenario.
~
More time spent
on critical steps
which inhibits team
work identifying plant status.
5.
Does the requal program adequately
prepare
you for the
requal
exam?
Yes
3
No 11
5a.
How could it be improved?
~
More simulator time focusing on basic system operation.
~
Do individual skills training.
6.
Is crew performance,
during the requal
exam, affected
by the
exam process?
Yes
19
No-
0
6a.
How?
Nervous.
Team effectiveness
and communication are reduced
because
individuals are reluctant to ask questions
or
make
comments for fear of looking incompetent or saying
the wrong thing.
January
23,
1992
Page
15 of 17
yP
4
RECOMMENDATIONS ACTIONS TO PREVENT RECURRENCE
1 ~
Provide additional training to licensed personnel
on control
room communications
and teamwork.
2 ~
~
Question
when in doubt.
~
Provide specific information.
~
Don't use slang.
~
Repeat
back complex commands.
~
Listen for critical plant parameters.
Provide additional simulator training.
~
Fundamental
operations.
~
Control of reactor vessel
parameters.
~
system manipulations.
3 ~
Review Operations'olicy
on procedure
usage during plant
4 ~
Review Operations'olicy
on the need for equipment
restoration procedure/procedure
sections.
5.
Implement rev.
4 of EPGs
and provide training to licensed
personnel.
Safety significance of "not all rods in."
Cold water transients.
6 ~
Develop guidance for evaluators.
Scenario deviations.
Use of multiple scenarios.
Proper weighing of mistakes
and recovery
and
considering
"what could have happened
approach"
versus
actual consequences.
Evaluating performance
and not just critical steps.
January
23,
1992
Page
16 of 17
7.
Identify methods of continually updating the evaluation
standard/process
to stay abreast
of new regulatory,
as well
as industry experience
issues.
8.
Train PP&L evaluators.
~
Evaluator guidance.
~
Rev.
4 of EPGs.
9.
Provide additional training to simulator instructors to
attain the goal of operating excellence
and transfer this
skill during simulator training.
10.
Ensure shift supervisors
and simulator instructors provide
consistent direction relative to operational
performance in
the simulator.
11.
Provide appropriate
feedback to the
NRC on this evaluation
and recommendations.
12.
Review the event,
the root cause analysis,
and the
recommended
corrective actions with licensed personnel.
January
23,
1992
Page
17 of 17
1992
ANNUAL OPERATE
TIMELINE FOR
RQtj1
Haf; 80
Jan,
85
Jan,
86
Jan,
87
May, 87
Ma
Dentan
Letter
Annual
Requal
I
Pllcrb NRC observed
Exam
3-RO's fafled wrftten
1-SRQ fafled wrftten
Annual
Requal
4 RQ's failed
wrftten
Annual
Re qual
ESWOf, Rev. 4
14 Pgs.
1 RO Walled Sfmulatar
2 SRO's fatled wrttten
Lax
on
Exc
Exc
Ind
Chc
Aug, 89
Jan,
90
GP-002 fssued
Annual
Requal
I
Jun,
90
ESW01,2,3,4+
121 Pgs,
Jul,
90
gRC EQP
Lope ctfon
Jan,
91
Annual
Requal
I
4 RQ WalLed Sfm
1 SRO Walled Sfm
2 af 20 NRC
observed fafled
Sfmulator
Type B Exam
1 Examfner far
2 Students
1 RO fafled wrftten
1 SRQ fafled wrftten
1 SRQ fafled Sfm
'3 PB.d
Sfmulator
Inftfal scenarfo
wrftten
Scenarfo
submftted to NRC
11/01/91
cenarlo
a
Reduce
one
.
fram 'crtterl
'obser v',
a~
malfunc.
8 cr
ep to reef
act on 2l
out
12/16/91
HSIV Isa+Scram
HPCI lost
No FV Lvl Cntl
REQ UALIFICATION
- AU'SE 'ANALYSIS
OPERATGR REHUAL ERT
PAGE
1 OF
37
Jun,
88
Aug, 88
Late
88
Jan,
89
ange
ual
lve
'y
5
Annual
Re qual
1 RQ fatled
Stnulator
Hack Exan
of New
Progr an
Pilots run
at 5 plants
Senhars
held
for Uttllttes
Constdered
change
Annual
Re qual
Tean Tests
Started
RQ's Walled S
observecI
PalFed
Stnulator
ESM01, REVo 5
79 Pgs.
Crlttcal Step Concept
Jan,
9P.
Annual
Re qual
I
ERT Establtshed
3 of 12 Indtv.
1 of 3 Teans
failed NRC observed
Scenar lo run,
results
tn
uncontrolled
InJ.
'With 8
I ods out
1/06/9R
NR@t gcognlzes
step
was rdssed
(t.e.~co tr lied
1/06/92
NRC adds crlttcal
step to SRQ and
1/06/92
SRQ, Tean
8
falled
ONE
OF
THREE
TEAMS FAILED THE ANNUAL
UNCONTROLLED INJECT
Could not
~ F.V. tn
S/U LeveL
CantroL
tta Power
ta FVP
Dtschar ge
Valve
Equtpnent
Fatlure
Scenarto
Destgn
EH1"
PCO-x
dtd nat
questton
conn and
One Tean
Fatted the
Re qual
Exon
Fatted
a
Crtttcal
Step
Tean
aUowed
UncontroUed
InJecttan
of'old
Vater
etta non S/D
Reaator
aUowed ta
go below
e00 PSI
halluaLLlj
opened
LS. Dtrected
Press to
550W00 PSI
ustng SRV
l
Scenarto
Oper attan
Destgn
PCO-U dtd
nat
questtan
Action
RS. dtd
nat
questtan
action
STA dtd
not
questton
8 Corrtr ol
Rods were
not
tlserted
Equtpnent
Fatlure
Scenar to
Destgn
step added
durtng NRC
r evtew
A>TAGHFVIENT E3
O&GRATOR RED UAL EAT
PAGE
1 OF
NRC OBSERVED
LICENSE
REQUAL EXAMINATION
GN 2
CONTROL
RODS
GUT
not
Available
HSIV
Isola+on
Scenario
HPCI not
Available
Scenarto
I not
ow FV <<as
t ln S/U
vel Control
Connunlca4on
1 CRD Punp
no't
Available
Scen arfo
END
Stlc?dng
EO. Du.ects
control to
13-54'
< 1037 PSI
Band cBctated
by RPS set
pcsnt
and
EQP
Vanted to
use
Conden.
to Recover
Level
Hot enough
Qgh Press.
In~ctlon to
contr o'l level
and Pr ess.
wtt?wn band
RCIC had
Inrttal
trfp
Scenario
Crtttcal
step
l not
htland
llS. not
aware lvl
recover?ng
wtth RCIC
Not told
love'l was
Recovering
Less than
Adequate
Cannuntca+on
Thought
level was
at -3S to
Std not
Flofwtol
adequately
iolved
k
Plan
ted
"tlctpa
1
CQAPIAg
?ual
US did not
realtze FV
BtC Loop
Bosch Vlvs
were open
PCG-u
stated
I
have S/U
level
control'otential
f'r a
thh d
scenario
be
ldressed
rately
Less thon
Adequate
Co~
perators
eUeve
ere ts a
o er rts?c
TaJeng
others'rrttcal
steps
Iafornatlon contcdned
ln this box
applicable to all ss
Addrbonal
observers
AUTO INITIATl
(FAILURE TQ
CQNTRQ
RQ FAILL
OPERATOR
UNABLE TC
QUICKLY Rl
RO FAILED NRC
OBSERVED
ANNUAL REQUAL
ALLOWED
UNCONTROLLED
NJ OF
COLD WT
DURING ATWS
RX LVL DECR TO
POINT OF HPCI/
RCIC INITIATION
FEEDWATER NOT
AVAIL TO FEED
VESSEL
FEEDW*TEl
PUMP TRIP.
ON
54'TA
COMMUNICATION
DID NOT
HANUALLY
INITIATE HPCI/
PCO
REPORT
COHFORT
NOT AWARE OF
LEVEL
TRAINING
INADEQUAI
ANTICIPATED
QUICK RECOVERY
OF FEEDWATER
NORHAL
EXPECTATION
LACK OF
TEAMWORK
COMMUNICE
OPERATOR REHUAL ERT
PASH
1 OF S
CIN jjLIRING ATWS
VESSEL LEVEL)
RE
OPERATOR
USED
PROCEDURE
CLEAR ON PLAN
QLICYi UNCLEAR QN
EXPECTATION FOR
IMPLEHENTING POLICY
(I,F
EMERG
SITUATIONS)
- STORE
PED
PROC
DID NOT
SPECIFICALLY
ADDRESS
MOT
RESTART
REQUESTED
CHANGE NOT
IHPLEHENTED
NOT CONSISTENT
WITH OPS
POLICY
PROCESS
TO
EVAL AND/QR
CONTROL CHANGE
REQUESTS
IS UNCLEAR
END
DID NOT EXPECT
54'ND
DID NOT
GO TO
S/U LEVEL
CONTROL
TEAH NQT AWARE
OF LEVEL
DID NOT HONITOR
LVL ADEQUATELY
DID NOT TAKE
HANUAL CONTROL
CONFIDENCE IN
3-ELEHENT
CONTROL AT
LQW POWER
DID NOT
RESPOND
TO
HI LVL ALARM
DISTRACTED BY
OTHER SCENARIO
PROBLEMS
END
/
TION
TIMELIr
AUTO INITIATION DURING ATi
FAIL'CENARIO
2
S/U 8 20/
TRANSFORMER
FIRE L ATVS
1. SWAP
HOUSE
LOADS TO
GEN
2. FW IN AUTO-3
ELEM CONTROL
HI TEMP ALARM
HAIN
TRANSFORMER
TURBIn
GEN L,I
AWARE
FAI
RESL
IN
RECOG, ATVS
MMEDIATE ACTIQ
MAN. SCRAM *RI
SRM/IRM POWER
9/
EO-102
CONTROL
PWR >5/,
SCRAM IN
U,S DIRECTED
PCO'S
TD
MONITOR SRV'S
L
DV PRESSURE
PC
MAX C'
PAGE 2 OF 3
'L
E
S
(F AILURE TQ
LQNTRQL LEVEL)
RE
TRIP
TEAM
FORMER
- .D
l ING
~5
MIN, FIRE
QUT. DELUGE
LEFT ON TO
COOL XFORMER
SCRAM DISCH
FILLING DUE TO
OPEN
1/2
U,S, DIRECTS
PCO-U
TO TAKE
NODE SWITCH TO
S/D AND PCO
COMPLIES
%SIMULATOR PROBLEM REPORT
,QN SIMULATOR MAY NOT
REFLECT PLANT UNANSWERED
JECT
X
FLOW
PCQ-X'JtQLD
TO
INHIBIT ADS
VERIFY CLEANUP
ISOL,
PCO
REPORTS
SLC INJECT
RX LVL +54
TURB L FW TRIP
WATER LEVEL
DECREASING FAST
UNEXPECTED BY
TEAN
U,S. DIRECTS
RECOVER
FEED
PUMP
-10
>1
ROD OUT
ARE ALL SCRAM
VLVS OPEN'l
NPO SENT
TO
CK
NPQ
REPORTS
SCRAM AIR
IS Bl ED QFF
PAGE
1
QF
2
TIMEI INE
US DIRECTS
RESET SCRAM-
PCO-X
US
QUESTIONS
WHEN RFP WILL
BE IN SERVICE
PCQ-U
STATES
WORKING QN IT
US EXPECTS
SOON,
KNEW
LEVEL WAS
DECREASING, DID
NQT EXPECT
-38'O
PROCEDURE
TO RECOVER
TRIPPED
FEED
PUMP
RESET
DELAYED
DUE TQ IRM U/S
US DIRECTS
RANGE UP
SCRAM RESET
REi
13'NO
Rj
PCQ-X
CONTROL
HPCI SPEED
> 2300
US DIRECTS
PCO-X OVERRIDE
PCO-X TAKES
TQ
3000
US
RECOGNI2
DECREASE
PR
TELL PCO-)
MONITOR HPC
RCIC DISCI
PRESS
TO AV
INJ, PCO
TA,,'PCI
TQ
0
SF
PCO
REDUCES
SPEED
ON'TINUATION
PAGE
S OF 8
-30'CIC
-38" HPIC
INITIATION
LEVEL STOPPED
DECREASING
US DIRECTED
PCO-X OVERRIDE
RX FEED
PUMP
ROLLING
LARGE VESSEL
LVL INCREASE
ALL MONITORING
POWER
RX PRESSURE
DECREASING
ECEIVED
ROD MOTION)
ZES
lESS
XI/
H
iOID
KES
'EED
RCIC BEGAN
INJECTING
US DIRECTS
PCO
TO STOP
INJECTION
NOT
FEEDING
+49; 475I
POWER
4
FREEZE
PAGE
2
OF
6
UNCONTROLLED INJECTIPN,
CAUSE
8,
E
PPE L AND NRC
DISAGREED
~NRC
US MISSED
CRITICAL STEP
WATE
CONTROL
WITH 2
RGD
QUT
CGULDN'T FAIL
W/G MISSING
CRITICAL STFP
PL PASSED
US
NRC
F AILED US
NRC DID NGT
CONSIDER BOTH
SCENARIOS IN
MAKING
DECISION
CRITICAL STEP
ADDED BY NRC
AFTER THE FAC
~NRC
OVERALL
PERFORMANCE
INADEQUATE
~PaL
US DID NGT
MISS CRITICAL
STEP
PPC L CONSIDERS
OTH SCENARIOS
IN MAKING
DECISION
~PS L
OVERALL
PERFORMANCE
WAS ADEQUATE
PERFORMANCE
WITH KNOWN
INFO WAS *DEQ)
BASED
ON
ACTIONS TAKEN
TO RECOVER
LVL CONTROL
RECOVERY
ACTIONS OUT-
WEIGHED
PROBLEMS
h
THERE WERE
NQ
CRITICAL PERF.
ERRORS
IN THE
RECOVERY
I ~
CONTROL
RODS
OLIT
FECT
IN
PERFORMANCE
PAGE
1 OF
1
NRC
PROGRAM
END
UNCONTROLLED
INJECTION CIF
COLD VATER
VITM 2
CR OUT
END
EVALUATOR DID
NOT REALIZE
IMPClRTANCE OF
COLD VTR INJ
V/2 RODS
CIUT
SEE
TEAM
CAUSE
8
EFFECT
CHART
EO-102 RPV
PRESS.
LEG
PROCEDURE
FRROR VAS NOT
RECOGNIZED
EVAL PROCESS
DIDN'T INCLUDE
RECCINSTRUCT ION
OF ACTIONS
TAKEN
NO TRIGGER
TO
DO
OUR
EVALUATION
STANDARD IS
NOT DEFINED
THIS VAS
OUR
PRACTICE
UNCONTROLLED INJECTION,
CAUSE
8,
EF
PPS L AND NRC
DISAGREED
SCENARIOS LOSS
OF RPS/DC-MSIV ISOLATION-
2
CONTROL
RODS FAILED TO INSERT
POST
SCENARIO
REVIEW ADDED THE
CONTROL GF LEVEL/
PRESSURE
CRITICAL STEP
NRC h PPKL CRITERIA/
EVALUATQRS DID NGT
AGREE ON ACCEPTABLE
PERfORMANCE
THE TEAM WAS
NRC
UN-SAT ON UNDER-
STANDING PLANT
RESPONSE
COMPETENCY
BASED QN SCENARIO,
THE TEAM DID NOT
MEET NRC CRITERIA
PL EVALUATQRS
PASSED
A TEAM THAT
NRC FAILED
PLL
THE TEAM
COMPLETED ALL
PRE-DETERMINED
CRITICAL STEPS
SATo
ALL INDIVIDUALS
PERFORMED CRITICAL
STEPS
SATISFACTORILY
BASED ON BOTH
SCENARIOS, THEY MET
OUR CRITERIA FOR
PASSING
POST
SCENARIO
REVIEW ADDED THE
CONTROL GF LEVEL/
PRESSURE
CRITICAL STEP
WEAKNESSES
LVL CONTROL
CQQLDOWN
Fw OPS
KNOWLEDGE
EG-102
PRESS
PPLL EVALUATORS DID
NOT CRITICALLY
EVALUATE COLD WATE
INJECTION (2
CR GUT)
RESULTED IN
1'N
UNDERSTANDING
SYSTEM RESPONSE
FROM SRO
CAUSE a EFFECT
CHART
CONT'ROL
ROI3S
OUT
.f T,
N
TEAM PERFORMANCE
PAGE
1 OF
1
- EVALUATED
'ICAL TASKS ONLY,
PERFORMANCE
WE SUBSTITUTED
FQR
QUR
EVALUATION
EXPECTATION
OUR EVALUATION
STANDARD IS NOT
DEFINED
- EVALUATORS
- CTATIQN WAS
i RIGOROUS THAN
DON'T UNDERSTAND
SOME FACETS OF
CURRENT NRC
STANDARDS
WE DO NOT HAVE
SUFFICKNT MECHANISM
TO ENSURE UNDER-
STANDING OF, AND
MAINTENANCE QF
CURRENT INDUSTRY
EXPECTATIONS
PPCL EVALUATORS ARE
NOT FORMALLY
TRAINED TO PPCL
QR
NRC STANDARDS
CURRENT INDUSTRY
EQP
STANDARDS ARE
NOT PPLL STANDARDS
PPCL
CONSIDERED
REV. 3 GUIDELINES
ACCEPTABLE
HAVE NOT ADOPTED
EPG REV. 4
PREVIOUS
MANAGEMENT
DIRECTION
END
EVALUATORS DID
CONSIDER 2 RODS
AS SIGNIFICANT
EVALUATED
CONSEQUENCES
OF
ACTIONS INSTEAD OF
POTENTIAL
CONSEQUENCES
DO NOT EMPLOY
'WOULD HAVE;
COULD
HAVE'PPROACH
NO POWER
CHANGE
SEEN
SCENARIO DESIGN
NOT CONSIDER
'IATION FROM
CEDURE
DEVIATION WAS NOT
RECOGNIZED BY PPKL
EVALUATQRS
END
~
a
a ma navacN
I
PAHE
1 OF
1
EVENT REVIEV REPORT
ANNUAL LICENSED OPERATOR
REQUALIFICATION
SYMBOLS LEGEND
ROOT
CAUSE
CAUSAL OR
CONTRIBUTING
FACTOR
NO FURTHER STEPS
BY
CAUSE
L EFFECT
TE CHNIQUE
REFER
TO OTHER
ON
SAME CAUSE
L EFFECT
CHART
TEXT NOT BOXED
INFORMATION NOT PERTINENT
TO SPECIFIC
ANALYSIS
TO
FROM ANOTHER
CAUSE-8
EFFECT
CHART
OPERATOR AEGUAI EAT
PENNSYLVANIA POWER
AI%3 LIGHT
COMPA2'A'ICENSED
OPERATOR REQUALIFICATION
EVALUATION AND RESPONSE
PLAN
DELAYREQVALIFICATIONEXAMS
PS'ORM NRC OF DELAY
COMPLETE JANUARY 13
RESM4ED EXAMS JANUARY27
PERFORM ROOT CAUSE ANALYSIS
COMPLETE JANUARY23
JUSTIFICATION FOR CONTIM3ED OPERATIONS
PROVIDED: MANAGER- NUCLEAR OPERATIONS, JAM7ARY 15
APPROVED: SUPERINTENDENT OF PLANT, JM67ARY 15
VERBALUPDATES PROVIDED WE~EKLY
OBSERVE AI%3 EVALUATE
azgvar.v rcmrox pROCESS
PERFORMiANCE OF EACH SIlVHJLATOREXAMINER
MANAGER-
CLEAR
OBSERVED:
S EXAIVIKNERS
7
EXPLANATIONS
2 MANAGEMENTREPRESENTATIVES
5 SIIVHjLATOROPERATORS
ALLPERFORIVKD SATISFACTORY
UPERINTENDENT
F PLANT
OBSERVED:
3 EXA1MP'lERS
1 MAI'MGEMENTREPREiSENTAIIVE
j. EXA1MII'%ATION
INDU TRY PEER EVAL ATIONS
COMPLETED: LASALLE- 2 EXAIVIINATIONS
HOPE CREEK - 2 EXAIVHNATIONS
PLANNED:
THREE MILEISLA&8)
PEACH BOTTOM
INDEPENDENT CONSULTANT
GENERAL PHYSICS
PARALLELGRADED ALLSI1VH3LATOREXAlVHNATIONSAFIER
RESUMPTION
ALLGRADINGIN AGREEMENT WXI'HPAL
RECOlVIIMENDATIONSTO IMPROVE OUR PROCESS
SIIVH3LATOREXAINSTATUS TO DATE
EXM4II.'R',D
20
PAAP5ED
FAILED
20
TEAMS
10
SINCE
N
14
TEAMS
RETEST SRO
RETEST RO
VAUTTENAI%3 JPM EXAMS
ON ORIGINALSCHEDULE
56 EXAMS COMPLETE
1 VAUTTENEXAMFAILU]RE
EVALVATOR
LEARNEDFROM
NRC TEAMINTERACTIONS
SELF-ANALYSIS
INDEPENDENT CONSVLTAJA" (GENEX4V PHYSICS)
G COVRSE (ED BOWLES)
JOINT MEETING- OPERATIONS APG)
G GROUPS
MANAGERS, SHIFI'UPERVISORS, SIMULATORINSTRUCTORS
REVIEWED:
ROOT CAUSE ANALYSIS
SURVEY RESULTS
ACTIONPLAN
Btu3NSTORMED POSSIBLE CHANGE<S:
IMPROVE EFFECIIVENESS OF FEEDBACK
INCREASED INDIVIDUALTASK
EMPHASIZE COlVB4VNICATIONS
FUTlURE PLANNED ACTIONS
OPERATOR
G (1992)
IMMKCH
REINFORCE CRITICALPARAlMETER CONTROL,
INFOMCATIONSHANXNGWFIHINTEAM,
COLD WATER RESTARTS,
MAKUALCOXHXOLOF HPCI, RCIC, AND
DETAILEDTRAININGON TARliAIEIRRCONTIIOL,
INFORMATIONSHING, QUESTIONING
ACTIONS OF OIHER TEAMMEMBERS, COLD
WATER ACCIDENTS,
ADS LOGIC, IKN/APRMOVERLAP,
MANUALCOXIROL OF HPCI, RCIC, AlitD
APRIL/JUNE
EVALUATIONSCENARIOS ON ABOVETOPICS
INDEPENDENT CONSULTANTEVALUATEAND
VERIFYEFFECI'IVENESS OF CORRECTIVE
ACTIONS
JUNE/AUGUST
TITANON REV 4 TO EOPS
MAY/AUGUST
REINFORCE IDEÃIIFIEDTOPICS
FUTVl&PLANNED ACTIONS
FACTOR LESSONS LEARNED INTO OUR SYSTEMATIC PROCESS TO
CONTROL REQUALIFICATION(MARCH 1992)
PROVIDE EVALUATOR
6 ANNUALLY(DECEMBER 1992)
PROVIDE EVALUATORPREP TBNE (DECEMBER 1992)
INDEPENDENT CONSULTANT ASSESS OUR EVALUATORSAND OPERATORS
PERIODICALLY(SEPTEMBER 1992)
EVALUATIONAZ'6) RESPONSE PLAN
LICENSED OPERATOR REQUALIFICATION
PENNSYLVANIAPOWER R LIGHT CO.
REVISION 2
UPDATED: FEBRUARY 14, 1992
Submitted:
H.Z. Palmer
Manager - Nuclear Operations
Submitted:
R.H. Lowthert
Manager - Nuclear Training
Approved:
H.G. Stanle
Superintendent
of Plant - SSES
Evaluation and Response
Plan
Licensed Operator Recpxalification
Rev. 2, 2/14/92
Page
1 of 11
Overview
Susquehanna's
performance during the Licensed Operator Annual
Requalification examinations
administered
during the week of
January
6,
1992: was unsatisfactory.
It does not meet
standards.
The Susquehanna
SES Evaluation and Response
Plan was developed to
identify specific weaknesses
and correct them. It consists
of
four major initiatives:
Program Evaluation
Operator Performance
Evaluation
Training
Program Corrections
and Improvements
In the program evaluation initiative we evaluate
our
requalification training and evaluation program utilizing
internal
PP&L resources
and outside support including independent
consultants,
INPO,
and sister utilities.
Important questions
we
must answer include:
Why were our passing
standards
lower than the
NRC?
Why did three operators
and one crew fail?
What errors did we make in responding to the changing
regulatory climate?
What fundamental
weaknesses
do we have in our program?,
Is continued operation justified based
upon operator
performance?
Are we capable of performing simulator examinations
that meet
PP&L performance
standards?
What lessons
learned
from industry experience
can be
incorporated into our programs?
Evaluation
and Response
Plan
Licensed Operator Requalification
Rev.
2, 2/14/92
Page
2 of 11
In the operator performance
evaluation initiative, with the
support of INPO and independent
consultants,
we are performing
critical evaluations of individual operator
and crew performance
to ensure safe operation
and identify weaknesses
and areas for
improvement.
Particular attention will focus on evaluating
control of critical parameters,
team members backing each other
up, ensuring all team members receive
needed information and
ensuring
team members
ask questions to gain needed
data or
direction.
During training we direct operators'ocus
back toward
fundamental operating principles.
Management will train
operators
on weaknesses
identified and evaluate their performance
to ensure mastery of the identified competency.
This plan is
updated continually as training needs
are identified in the
evaluation process.
Training identified, to date, will strengthen
operator
competency
on operating practices
such
as parameter control and team work.
Specific technical knowledge
and skill topics will also
be
relearned.
Training is scheduled for individuals who fail any
requalification exam, for all operators
on revision
4 to the
Emergency Operating procedures
and for all operators
on general
examination weaknesses.
Additionally, evaluators
who perform
simulator evaluations will receive training on PP&L standards
and
the exam process.
Program correction and improvement initiatives upgrade the
Licensed Operator Requalification Program to correct deficiencies
and enhance
the program.
This includes action using independent
consultants to ensure the program and our operators
maintain the
high level of performance that we demand.
Implementation of revision
4 to the Emergency Operating
Procedures
has already
been scheduled.
The addition of a week
for examination preparation for PPGL examiners
and an evaluator
training course are planned actions.
Other actions will be identified and scheduled
as results of the
evaluation
and self-assessment
activities become available.
These actions will preclude this unsatisfactory situation from
occurring again.
Evaluation and Response
Plan
Licensed Operator Requalification
Rev. 2, 2/14/92
Page
3 of ll
Team members responsible for the implementation of this
evaluation
and response
plan are:
Arthur S. Fitch, Supervisor Operations Instruction
William H.. Lowthert, Manager
Nuclear Training
Thomas
R. Markowski, Day Shift Supervisor
Operations
Howard Z. Palmer,
Manager
Nuclear Operations
Evaluation and Response
Plan
Licensed Operator Requalification
Rev. 2, 2/14/92
Page
4 of 11
Program Evaluation
This initiative reviews
and evaluates
our Requalification
Training and Evaluation process.
This review and evaluation uses
PPGL resources
and includes
assessments
by an independent
consultant
and industry peer evaluators.
After corrective
actions are implemented
INPO will be asked for an evaluation to
verify that needed
improvements
have been achieved.
1 ~
2 ~
3 ~
Delay performance of requalification simulator
examinations
during this annual cycle until clear
pass/fail standards
are understood
by all examiners
and
the Manager of Operations
has verified that exams will
be given consistently with those standards
(H.J.
Palmer,
January
13, 1992).
Complete
Inform NRC Region I of our delay in completing
simulator examinations
(W.H. Lowthert, H.J. Palmer,
January
13, 1992).
Complete
Use the root cause analysis process to accomplish these
activities
(R.M. Peal,
begin January
15,
1992).
Complete
Identify fundamental
problems or programmatic
weaknesses
in the Licensed Operator
Requalification Training and Evaluation Program.
Determine why, initially, PPGL evaluators
graded
no operator
as failing on the simulator, while NRC
evaluators
graded
one
and one team
as failures.
Determine
why 25% of the operators
examined failed
the exam during the week of January
6,
1992.
Determine if PP&L response to the changing nuclear
regulatory climate has
been appropriate.
Areas of
inquiry should include examining methods,
examining material,
emergency operating procedure
revisions,
operating philosophy,
procedural
compliance,
and operator performance
standards.
Evaluation and Response
Plan
Licensed Operator Requalification
Rev. 2, 2/14/92
Page
5 of ll
0
4 ~
Provide justification for continued operation
considering the examination results of January
6 and 7,
1992.
Use data from recent operating experiences
at
Susquehanna,
the
1992
requalification examinations,
in-plant operator
performance,
weekly exam results,
previous annual
exam
results,
SOORs,
and
NSAG surveillances to determine if
operator performance currently meets
Susquehanna
standards
(H.J. Palmer,
B.S. Stitt).
Preliminary justification to the Superintendent
of
Plant
(January
15, 1992).
Complete
5.
On-going justification based
upon exam results
(January
15
March 7, 1992).
In Progress
Observe
and evaluate the requalification process
and
the performance of Susquehanna
evaluators
during the
current requalification examination period
(W.H. Lowthert, complete by March 20,
1992).
Manager-Nuclear Training evaluate the Susquehanna
requalification process
including evaluating
each
examiner during the performance of two simulator
examinations
(W.H. Lowthert, complete
by March 20,
1992).
In Progress
Superintendent
of Plant
Susquehanna
evaluate the
Susquehanna
requalification process
including
evaluating
each examiner during the performance of one
simulator examination
(H.G. Stanley,
complete
by
March 20, 1992).
In Progress
Have an industry peer with recent experience in NRC
Licensed Operator requalification examinations
evaluate
the Susquehanna
requalification process
including
evaluating examiners
and
exam material during the
performance of simulator examinations
(W.H. Lowthert,
complete
by March 20,
1992).
In Progress:
Hope Creek
and La8alle Complete
A consultant with recent experience in NRC Licensed
Operator requalification examinations
evaluate the
Susquehanna
requalification process
including
evaluating examiners
and
exam material during the
performance of simulator examinations
(W.H. Lowthert,
start January
17,
end March 20,
1992).
In Progress:
General Physics is the Consultant
Evaluation and Response
Plan
Licensed Operator Requalification
Rev. 2, 2/14/92
Page
6 of 11
6.
Utilize an independent
consultant to verify that
corrective actions
have been effective in improving the
Requalification Program after corrections identified
through the root cause analysis
and the evaluations of
simulator examiner performance
have been incorporated
into the program
(W.H. Lowthert, June 1992).
7 ~
After the implementation of our corrective actions .and
program modifications including operator training,
utilize INPO and other utilities to assess
the results
of our corrective actions.
These
assessments
include
both program evaluations
and examinations of operators
to ensure that desired
improvements
have been
made
(W.H. Lowthert, August 1992).
Evaluation and Response
Plan
Licensed Operator Requalification
Rev. 2, 2/14/92
Page
7 of 11
~
~
Operator-Performance
Evaluation
This initiative'uses
PP&L,. an independent
consultant,
and
resources
to identify operator
competency to perform licensed
operator duties at Suscgxehanna.
It includes completing the
operator examinations during this cycle and
a mid-program
assist visit.
Using PP&L and independent
consultant resources,
evaluate the remaining licensed operators
and
supervisors
using approved examination material.
Identify individual operator
competency
and each team's
ability to operate
as
a unit.
Identify individual
weaknesses
and overall operational
areas for
improvement
(H.J. Palmer,
January
13 to March 7, 1992).
In Progress
2.
Using PP&L and independent
consultant resources,
provide critical evaluations of operator performance in
the simulator.
Pay particular attention to control of
critical parameters
and to team members
backing each
other up, ensuring all members receive
needed
information and ask questions to gain needed
data or
direction (T.R. Markowski, A.S. Fitch, January
27 to
March 7, 1992).
In Progress
3 ~
Complete written and
JPM examinations for all operators
per schedule
(T.R. Markowski, A.S. Fitch, January
13 to
February
21, 1992).
In Progress
4 ~
Using an INPO assist visit, assess
the performance of
our operators
by evaluating at least two control room
teams in the simulator during the performance of
emergency operating procedure
scenarios
(W.H. Lowthert,
H.J. Palmer,
August 1992).
Evaluation and Response
Plan
Licensed Operator Requalification
Rev. 2, 2/14/92
Page
8 of 11
Training
,This initiative ensures that as deficiencies
are identified
through evaluation processes all necessary training is received.
This plan is updated continually as training needs
are identified
in evaluation initiatives.
Provide training to annual requalification
exam
simulator evaluators for 1992 that includes the exam
process,
management
expectations,
and standards
for
acceptable
operator performance
on simulator
examinations
(H.J. Palmer,
January
24,
1992).
Complete
2.
Manage the remedial training and examining of operators
who fail requalification examinations
(A.S. Fitch).
In
Progress
Remove individuals from licensed duties
(H.J. Palmer).
Develop an individual remedial training and examination
plan for each operator
(A.S. Fitch).
Provide remedial training (A.S. Fitch, T.R. Markowski).
Examine the operator
and return to licensed duties or
identify future training or non-licensed
duty
assignments
(H.J. Palmer).
Evaluation
and Response
Plan
Licensed Operator Requalification
Rev. 2, 2/14/92
Page
9 of 11
3 ~
Provide prompt remedial training for all operators in
areas identified as general
weaknesses.
Immediately after the exam cycle (February
21 to
March 16) reinforce critical parameter control, sharing
information among the team members,
cold water restarts
and manual control of HPCI, RCIC, and feedwater.
This
will include approximately two hours of training for
each operator
(T.R. Markowski, March
2 to March 20,
1992) .
Cycle
1 (March 16 to April 24) Conduct detailed
training on:
parameter control
information sharing
among team members
questioning actions of other team members
manual control of HPCI
manual control of RCIC
manual control of feedwater
cold water accidents
ADS logic
IRM/APRM overlap
(T.R. Markowski, A.S. Fitch)
Cycle
2 (April 27 to June
5) Evaluate operators
on the
topics identified in cycle
1 to assess
performance
improvement status
(T.R. Markowski).
Cycle
3 and
4
(June
8 to August 28) Train operators to
use revision
4 Emergency Operating Procedures
(A.S.
Fitch).
Note:
Operations will begin using revision
4 of the
on September
11.
Cycle
4
(May 20 to August 28) Review and reinforce
training covered in cycle
1 (T.R. Markowski).
Evaluation
and Response
Plan
Licensed Operator Recpxalification
Rev. 2, 2/14/92
Page
10 of ll
Program Corrections
and Improvements
Correct and improve the Licensed Operator Requalification
Training and Evaluation Program based
upon evaluation information
received utilizing independent
consultants to ensure
problems to
not reoccur.
This plan will grow with the addition of action
items to correct problems
found in the evaluation process.
Identify actions
and develop
a plan to improve the
Licensed Operator Requalification Training and
Evaluation Program in response
to the outcome of the
root cause analysis effort (A.S. Fitch,
W.H. Lowthert,
March 27, 1992).
2.
Begin using revision
4 to the
(H.G. Stanley,
September
11,
1992).
3.'or future year requalification examinations,
provide
evaluator training to all examiners that includes
standards
for acceptable
performance
(A.S. Fitch,
December
1992).
4 ~
5.
For future year requalification examinations,
provide a
prep week to examiners similar to the
NRC examiner's
prep week to review examination material
and rehearse
simulator scenarios
and Job Performance
Measures
(A.S. Fitch,
December
1992).
During each requalification year, three months prior to
the annual examination,
have
an independent
consultant
perform an assessment
of our evaluators
and examine
a
representative
sample of our operators,
that includes
at least three control room teams, to identify and
correct problems prior to NRC administered
examinations
(W.H. Lowthert, H.J. Palmer,
September
1992).
Evaluation and Response
Plan
Licensed Operator Requaliflcation
Rev. 2, 2/14/92
Page
11 of ll
(4,