ML17312B527
| ML17312B527 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 06/24/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML17312B526 | List: |
| References | |
| 50-528-97-10, 50-529-97-10, 50-530-97-10, NUDOCS 9706270057 | |
| Download: ML17312B527 (24) | |
See also: IR 05000528/1997010
Text
ENCLOSURE
U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Docket Nos.:
License Nos.:
Report No.:
Licensee:
Facility:
Location:
Dates:
Team Leader
Inspectors:
50-528
50-529
50-530
NPF-51
50-628/97-1 0
50-629/97-10
50-530/97-1 0
Arizona Public Service Company
Palo Verde Nuclear Generating Station, Units 1, 2, and 3
5951 S. Wintersburg Road
Tonopah, Arizona
May 20-23, 1997
Gail M. Good, Senior Emergency Preparedness
Analyst
Reactor Engineer
Thomas H. Andrews Jr., Radiation Specialist
Thomas H. Essig, Chief
and Environmental Health Physics Section
Office of Nuclear Reactor Regulation
Approved By:
Stephen
P. Klementowicz, Health Physicist
Office of Nuclear Reactor Regulation
Blaine Murray, Chief, Plant Support Branch
ATTACHMENT:
Supplemental
Information
97062700S7
970624
ADOCK OS000528
-2-
EXECUTIVE SUMMARY
Palo Verde Nuclear Generating Station, Units 1, 2, and 3
NRC Inspection Report 50-528/97-10; 50-529/97-10; 50-530/97-10
A routine, announced
inspection of the licensee's
performance
and capabilities during the
full-scale, biennial exercise of the emergency
plan and implementing procedures
was
performed.
The inspection team observed activities in the control room simulator,
technical support center, operations support center, and emergency operations facility.
Plant Su
ort
Overall, control room staff performance was satisfactory.
An exercise weakness
was identified for not promptly recognizing and declaring the notification of
unusual event.
Offsite agency notifications were timely. Analysis of plant
conditions was good, in that, effective command and control and questioning
attitudes were maintained by control room staff throughout the exercise.
Three-part communications
were not used in some instances,
and communications/
announcements
concerning plant status were delayed on some occasions
(Section P4.2).
Overall, the technical support center's performance was good.
The emergency
coordinator exercised good command and control.
The staff was quick to identify
potential problems and worked with the control room to trend data to ensure proper
actions were being taken.
Classifications and notifications to the NRC were correct
and timely. Some plant announcements
contained unclear information (Section
P4.3).
Overall, the operations support center staff's performance was good.
Center
personnel effectively demonstrated
the capability to gather relevant information,
form and brief teams, and implement in-plant repair tasks directed by the technical
support center.
Information flowed smoothly between center managers,
and staff
briefings were effective.
Habitability surveys were not sufficiently comprehensive
to characterize the potential exposure
received by center occupants.
In-plant team
debriefings were not always documented.
Radiation protection staff did not
understand
the distinction between ion chamber measurements
made in the window
open versus window closed mode (Section P4.4).
Overall, the emergency operations facility staff's performance was generally good.
Offsite protective action recommendations
were developed
in a timely manner.
Less than satisfactory performance was observed
in the area of offsite agency
notifications.
An exercise weakness
was identified for a failure to notify offsite
agencies of a protective action recommendation
upgrade.
Communications
and
-3-
information control were not always effective.
Dose assessment
and field team
control activities were generally good.
Default values used in dose projections were
not always accurate and could have negatively affected protective action
recommendations.
Communications with field teams and dose assessment
form
completion were inconsistent.
Interactions with offsite agency representatives
were
effective (Section P4.5).
The initially submitted scenario appeared
minimally challenging, and the package
was incomplete.
The inspectors determined that the final exercise scenario was
sufficiently challenging to test emergency response
capabilities and demonstrate
onsite exercise objectives.
Exercise control was sufficient.
Some activities were
over-simulated
(Section P4.6).
The critique process was not fully effective in identifying issues in need of
corrective action and areas for improvement.
With the exception of the technical
support center, the post-exercise facility critiques did not include input from
exercise participants.
The post-exercise
and management
critiques tended to focus
on strengths
and positive observations
(Section P4.7).
-4-
IV. Plant Su
ort
P4
Staff Knowledge and Performance in Emergency Preparedness
P4.1
Exercise Conduct and Scenario Descri tion 82301 and 82302
The licensee conducted
a full-scale, biennial emergency preparedness
exercise
beginning at 8 a.m. on May 21, 1997.
The exercise was conducted to test major
portions of the onsite (licensee) and offsite emergency
response
capabilities.
The
licensee activated its emergency response
organization and all emergency response
facilities. The Federal Emergency Management Agency evaluated the offsite
response
capabilities of the State of Arizona and Maricopa county.
The Federal
Emergency Management Agency will issue
a separate
report.
The scenario for the exercise was dynamically simulated using one of the licensee's
control room simulators.
The initial scenario conditions included Unit 2 operating at
100 percent power for the last 116 days.
The operating crew was informed that
reactor coolant activity had been increasing for the last 10 days and had stabilized
at 1.08 microcuries per gram dose equivalent iodine for the preceding 47 hours5.439815e-4 days <br />0.0131 hours <br />7.771164e-5 weeks <br />1.78835e-5 months <br /> and
45 minutes.
Exceeding reactor coolant activity allowable limits (greater than
1 microcurie per gram for 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />) met the conditions for a notification of unusual
event.
Subsequent
simulated events were as follows:
A fire occurred in the control panel for Emergency Diesel Generator
B, which
damaged
the panel and tripped a differential relay.
This rendered the diesel
generator inoperable and resulted in escalation to an alert.
A fork liftbacked into some piping attached to the refueling water tank,
which resulted in a leak of approximately 300 gallons per minute.
~
A tube leak of approximately 30 gallons per minute developed
in Steam
Generator
1.
~
The main feedwater economizer valve for Steam Generator
1 cycled fully
open causing excess feedwater addition to the steam generator.
This
resulted in a reactor trip and main steam isolation from high-high level in
1. This transient also increased the steam generator tube
leakage from 30 gallons per minute to approximately 700.
The excess
feedwater overfilled the steam generator and caused
a steam line break
outside the containment
in the main steam support structure, resulting in a
site area emergency declaration and an unmonitored release.
-5-
~
High Pressure
Safety Injection Pump A performance
degraded
and eventually
failed, leaving High Pressure Safety Injection Pump 8 as the only operable
high pressure
pump, but without a redundant power supply.
~
Dose rates at the site boundary increased
and the event was upgraded to a
general emergency.
The remainder of the scenario consisted of efforts to depressurize
and cool the
reactor coolant system to reduce the leakage through Steam Generator
1.
P4.2
Control Room
a,
Ins ection Sco
e 82301-03.02
The inspectors observed
and evaluated the control room simulator staff as they
performed tasks in response to the exercise scenario conditions.
These tasks
included event detection and classification, analysis of plant conditions, offsite
agency notifications, internal and external communications,
and adherence
to the
emergency plan and procedures.
The inspectors reviewed applicable emergency
plan sections, departmental
procedures,
instructional guides, logs, checklists, and
notification forms generated
during the exercise.
b.
Observations
and Findin s
The control room crew did not properly classify one of the two events that occurred
prior to technical support center activation.
The shift supervisor did not recognize
the proper emergency action level for declaring the notification of unusual event.
Emergency Action Level V-52 of Departmental Procedure
16DP-OEP13, "Emergency
~
Classification", Revision 0, required
a notification of unusual event be declared
when reactor coolant activity exceeded technical specification limits. This
procedure stated that emergency declarations
should be made within 15 minutes
from the time conditions are available.
The technical specification limits for reactor coolant activity were exceeded
at
8:15 a.m.
However, by 8:30 a.m., the shift supervisor had not yet declared
a
notification of unusual event.
To keep the exercise on schedule, the controller
provided the emergency action level information via a contingency message.
The
shift supervisor declared
a notification of unusual event at 8:34 a.m.
The failure to
promptly recognize and declare the notification of unusual event was identified as
an exercise weakness (50-528;-529;-530/9710-01).
In response,
the licensee stated that information about the impending emergency
classification would have been provided during the shift turnover.
The inspectors
acknowledged this comment, but did not agree that it was an acceptable
basis for
the failure, since those present in the control room simulator failed to review all
applicable emergency action levels.
It should be noted that an additional shift
-6-
technical advisor was present and that the initial conditions presented
at 7:55 a.m.
indicated that reactor coolant activity had stabilized at 1.08 microcuries per gram
dose equivalent iodine for the preceding 47 hours5.439815e-4 days <br />0.0131 hours <br />7.771164e-5 weeks <br />1.78835e-5 months <br /> and 45 minutes.
This means that
control room personnel
had 35 minutes to recognize and classify the event.
The site shift manager, after consultation with the shift supervisor, properly
classified the alert after the fire damaged
Diesel Generator
B and rendered it
An auxiliary operator reported the damage at 8:50 a.m. and the site
shift manager declared the alert at 8:55 a.m.
Offsite agency notifications were correct and timely. For both the notification of
unusual event and alert classifications, the satellite technical support center
communicator and the unaffected shift technical advisor made timely notifications
to offsite agencies
and the simulated NRC Operations Center, respectively.
The control room staff maintained very good command and control throughout the
exercise.
The shift supervisor maintained
a good safety conscience
and consulted
with both the control room supervisor and site management
before making major
decisions that would affect plant conditions.
The inspectors observed the following
examples:
~
After the leak was discovered
in the refueling water tank, the shift supervisor
consulted with the operations director and decided not to escalate the event
because
the public was not yet affected.
The shift supervisor based this
decision on indications from radiation monitors.
The shift supervisor consulted with the site shift manager and operations
director on reactor coolant pump operation.
Plant cooldown affected the net
positive suction head of the pumps and continuing their operation would
have required stopping the cooldown.
The shift supervisor decided to secure
the reactor coolant pumps because
plant cooldown was a higher safety
priority.
The cooldown without reactor coolant pumps resulted in voiding in the
reactor head.
After this condition was detected the shift supervisor
consulted with the reactor operators
and control room supervisor and
discussed
the possibility of energizing pressurizer heaters to relocate the
bubble.
The shift supervisor again placed priority on plant cooldown by
continuing the cooldown without energizing the heaters.
The control room staff maintained
a good questioning attitude during the exercise.
The inspectors observed that the primary reactor operator continued to suggest
ways to eliminate the void in the reactor head even when the operator's
-7-
suggestions
were not followed. The inspectors also observed that the control room
supervisor expressed
serious concern about continuing the plant cooldown without
using high pressure safety injection pumps when reactor level instrumentation was
lost due to a malfunction in the qualified safety parameter display system.
Communications within the control room and with the field, while
good, still could have been improved.
The inspectors were informed that
three-part communications were expected to be used on all occasions.
Three-part communications
involve:
(1) information communication by provider,
(2) information restatement
by receiver, and (3) information confirmation by
provider.
While the inspectors observed that three-part communications were
normally used in the control room, the practice was not used in the following
instances:
~
The reactor operator who received information on the diesel generator fire
did not repeat back the information.
~
The auxiliary operator who received
a request for a specific valve or
instrument number to pinpoint the refueling water tank leak did not repeat
back the request.
~
The control room supervisor did not repeat back information received on the
Radiation Monitor RU-142 alarm condition.
The inspectors observed
several other instances
where communications
could have
been improved.
While these instances
had no direct consequences
in the exercise,
they indicated the potential for errors.
~
The emergency coordinator did not inform the satellite technical support
center and control room staffs when the satellite technical support center
activated.
~
The control room staff did not immediately announce the Radiation
Monitor RU-142 alarm and did not inform the control room supervisor until 2
minutes after receipt.
The control room supervisor did not communicate the location of the steam
leak to the shift supervisor until 11 minutes after information was available
on elevated dose rates in the main steam support structure.
The reactor operator who received information on High Pressure Safety
Injection Pump A performance informed the primary reactor operator instead
of the control room supervisor.
-8-
Logkeeping in the control room simulator and satellite technical support center was
satisfactory.
The satellite technical support center communicator and the radiation
protection monitor kept logs on sheets provided in the emergency
plan procedures.
Control room staff and the shift technical advisor kept logs on scratch paper to be
transferred to official logs at a later time. The licensee indicated this was normal
practice for control room personnel
~
C.
Conclusions
Overall, control room staff performance was satisfactory.
An exercise weakness
was identified for not promptly recognizing and declaring the notification of unusual
event.
Offsite agency notifications were timely. Analysis of plant conditions was
good in that effective command
and control and questioning attitudes were
maintained by control room staff throughout the exercise.
Three-part
communications
were not used in some instances,
and communications/
announcements
concerning plant status were delayed on some occasions.
P4.3
Technical Su
ort Center
a.
Ins ection Sco
e 82301-03.03
The inspectors observed
and evaluated the technical support center staff as they
performed tasks necessary to respond to the exercise scenario conditions.
These
tasks included staffing and activation, accident assessment
and event classification,
NRC notifications, personnel accountability, facility management
and control, onsite
protective action decisions and implementation, internal and external
communications,
assistance
and support to the control room, and prioritization of
mitigating actions.
The inspectors reviewed applicable emergency plan sections,
departmental
procedures,
instructional guides, and logs.
b.
Observations
and Findin s
The technical support center was activated within 30 minutes of the alert
classification.
The emergency coordinator announced
when the technical support
center was activated and when emergency coordinator duties were assumed
from
the control room.
The inspectors considered the activation process coordinated
and
efficient.
Since the exercise took place during normal working hours, multiple individuals
reported to the technical support center for key positions.
Once it was determined
that these positions would be staffed by the appropriate individuals, the additional
responders
left the facility. The inspectors determined that the technical support
center was adequately staffed.
-9-
Upon activation, the emergency coordinator in the technical support center assumed
the responsibility to classify emergency events.
The emergency coordinator
promptly and correctly classified the site area and general emergency.
The
inspectors observed that the technical support center staff worked as a team to
identify possible conditions that would require upgrading the emergency
classification.
The primary emergency notification system communicator was assigned to the
Notifications to the NRC regarding the site area and the
'eneral emergency classifications were made quickly after event declarations.
As part of the scenario, assembly of nonessential
personnel was simulated.
Using
real plant security computer data, the security director generated
a listing of all
unaccounted
for personnel.
When the security director handed the list to the
emergency coordinator,
a controller substituted the list with exercise data.: The
initial accountability process was completed in about 28 minutes.
Since the
process was completed within 30 minutes, it was considered timely.
The inspectors observed
personnel using the accountability card reader in the
technical support center as part of the initial accountability process.
During the
initial accountability phase, personnel were reminded to use the card reader if they
had riot already done so.
The inspectors determined that initial accountability was
performed consistent with the licensee's
procedures.
The inspectors initially determined that continuous accountability was not properly
maintained in the technical support center.
A potential exercise weakness
was
identified at the May 23, 1997, exit meeting.
However, on June
11 and 12, 1997,
the licensee provided additional information that resolved the continuous personnel
accountability concerns.
On June 13, 1997, the licensee was informed that the
issue was no longer considered
an exercise weakness
and that continuous
accountability was satisfactorily maintained in the technical support center.
During the initial activation, the inspectors observed
radiation protection personnel
performing habitability surveys, the setup and activation of a noble gas monitor, and
the setup of an air sampler with a charcoal filter cartridge.
Following the
radiological release, the inspectors confirmed that barricades,
signs, and a frisker
were placed at the center entrance.
Radiation protection personnel performed
routine habitability surveys.
The inspectors concluded that habitability within the
center was appropriately monitored and maintained.
A barricade sign at the center exit instructed personnel to notify radiation protection
prior to exit. The inspectors observed that radiation protection personnel provided
instructions regarding the route to take upon center exit and any additional
measures that were needed
due to the release.
The inspectors
observed good
briefings by radiation protection personnel.
-10-
The inspectors observed that some personnel who entered the center used poor
frisking techniques.
Poor frisking techniques
included holding the probe too far
from the surface, moving the probe too fast, and not surveying portions of the
body.
Radiation protection personnel
provided assistance
by actually performing the
frisk or by coaching.
As a result, the inspectors did not observe anyone entering
the center without being adequately monitored for contamination.
However, the inspectors noted that radiation protection personnel were not located
where they could readily observe personnel entering the center.
Therefore, the
inspectors concluded that poor frisking techniques
could potentially impact center
habitability since personnel
could enter without being noticed by radiation protection
personnel.
The inspectors
made the following observations
related to dosimeter use:
During the simulated radiological release,
one individual exited and re-entered
the center without either a self-reading dosimeter or thermoluminescent
dosimeter.
Most technical support center personnel wore thermoluminescent
dosimeters
but not self-reading dosimeters.
Planning Standard
K.3.a of NUREG.-0654 states,
in part, "Each organization shall
make provisions for distribution of dosimeters,
both self-reading and permanent
record devices."
Section 6.7.1 of the licensee's
emergency
plan stated,
"Emergency workers carry dosimeters
in addition to TLDs [thermoluminescent
dosimeters]."
Inspectors noted that a supply of pocket ion 'chambers was available
in the technical support center supply locker.
After the exercise, the inspectors discussed
dosimetry requirements with the
licensee.
The discussion focused on the definition of "emergency worker." The
licensee presented
information to show that personnel
in the technical support
center were not considered to be emergency workers simply because they were
responding to an emergency at the technical support center.
The licensee also
provided documentation
regarding the relaxation of monitoring requirements
consistent with 10 CFR Part 20. The inspectors pointed out potential interpretation
differences associated
with the term "emergency worker." The licensee
acknowledged
the need to clarify the term in the emergency plan.
Communication within the technical support center was very good.
Throughout the
exercise, the emergency director exercised very good command and control.
The
layout of the technical support center allowed the emergency director to quickly
obtain information related to plant and radiological conditions and to communicate
with other emergency
response
facilities. Good briefings were conducted
on a
frequent basis.
The inspectors observed that individuals consistently used
three-part communications
during all forms of verbal communication.
-11-
The emergency coordinator requested
frequent plant-wide announcements
to
provide the emergency classification, important information, and directions to site
personnel.
Some information in the announcements
was not clearly stated.
Examples included:
~
Several announcements
included the statement that no eating, drinking,
smoking, or chewing was permitted in the vicinity of Unit 2 due to
radiological conditions.
There was no guidance provided as to what areas
were considered
as the "vicinity"of Unit 2.
~
Several announcements
included information that a radiological release
was in progress
and that the wind was blowing towards Administration
Buildings A and B. No guidance was provided regarding the expected
response
by personnel
assembled
in these areas.
The emergency coordinator used the telephone to maintain regular contact with the
other emergency response
facilities. There were occasional discussions
regarding
the status of various tasks; however, since a visual method to track task status was
not used, questions concerning the completion status of several tasks arose near
the end of the exercise.
The inspectors noted that a similar observation was made
during the last biennial exercise (NRC Inspection Report 50-528;-529;-530/95-04).
The inspectors determined that the current method of tracking tasks in the technical
support center was not fully effective.
C.
Conclusions
Overall, the technical support center's performance was good.
The emergency
coordinator exercised good command and control.
The staff was quick to identify
potential problems and worked with the control room to trend data to ensure proper
actions were being taken.
Classifications and notifications to the NRC were correct
and timely. Some plant announcements
contained unclear information.
P4 4
0 erations Su
ort Center
a.
Ins ection Sco
e 82301-03.05
The inspectors observed
and evaluated the operations support center staff as they
performed tasks in response to the scenario conditions.
These tasks included
functional staffing and in-plant emergency response
team dispatch and coordination
in support of control room and technical support center requests.
The inspectors
reviewed applicable emergency plan sections, departmental
procedures,
instructional guides, logs, checklists, and forms generated
during the exercise.
-1 2-
Observations
and Findin s
The operations support center staff began reporting within a few minutes following
the 8:55 a.m. alert classification.
Although the center was not declared operational
until approximately 9:40 a.m., several teams were formed and dispatched
prior to
this time, decreasing
the impact of the relatively slow activation.
Overall, command and control in the operations support center was good.
Noise
levels and distractions were kept to a minimum throughout the exercise.
Tasks
were conducted
in accordance
with priorities set by the technical support center.
In
addition, the operations support center staff performed several tasks in anticipation
of the need for certain information.
Habitability surveys, although frequently performed, were not sufficiently
comprehensive
to characterize the potential exposure received by center, occupants.
Surface contamination measurements
appeared to be used as a surrogate for direct
measurements
of airborne activity. During most of the exercise, participants knew
that the primary coolant contained high radioiodine concentrations
and that this
activity was later released
via a steam generator tube failure and main steam line
break.
The failure to collect air samples
as part of the habitability surveys could
have resulted in little or no warning to operations support center occupants
regarding the presence
of airborne radioiodine.
In-plant response
teams were sufficiently briefed and debriefed for each assigned
task.
The, briefings were thorough and emphasized
task performance
issues,
personnel safety, and radiation protection.
The briefings included important
information and observations
pertinent to subsequent
team dispatch, such as the
existence of steam and radiological releases/conditions.
Twenty-six teams were
dispatched from the operations support center.
Form EP-0131, "In-Plant Team Briefing," was effectively used to document the
results of team briefings.
However, team debriefings, although conducted
regularly,
were not always documented.
Specifically, debrief comments were not
documented
about 20 percent of the time, and team return time was not
documented
about 40 percent of the time. Additionally, the team dispatch time
was not recorded 20 percent of the time. These failures to record information,
particularly with regard to team return time, could have led to confusion regarding
whether the team completed its mission.
The operations support center management
staff properly maintained accountability
of teams and team members.
Good radio and telephone contact was maintained
with the teams.
Information resulting from these communications was promptly
shared among key staff in the operations support center and then relayed to
personnel
in the technical support center.
-13-
Exercise participants generally understood
the technical aspects of their assigned
tasks; however, radiation protection staff in the operations support center appeared
to lack knowledge regarding the distinction between radiation measurements
made
with an ion chamber in the window open versus window closed mode.
This
apparent lack of knowledge may have caused
exercise participants to not question
scenario data which contained air sample results that were extremely low in value
given that they were collected within an established
plume.
For example, on two occasions (11:12 a.m, and 12 noon), teams reported exposure
rate measurements
which indicated that the measurement
was made within the
plume (the window open measurement
was significantly higher than the window
'losed
measurement).
This information, coupled with the knowledge that
radioiodine releases
were on-going, should have caused the radiation protection
staff to question the lack of activity on air samples collected at the same time and
location.
Conclusions
Overall, the operations support center staff's performance was good.
Center
personnel effectively demonstrated
the capability to gather relevant information,
form and brief teams, and implement in-plant repair tasks directed by the technical
support center.
Information flowed smoothly between center managers,
and staff
briefings were effective.
Habitability surveys were not sufficie'ntly comprehensive
to characterize the potential exposure
received by center occupants.
In-plant team
debriefings were not always documented.
Radiation protection staff did not
understand
the distinction between ion chamber measurements
made in the window
open versus window closed mode.
Emer enc
0 erations Facilit
Ins ection Sco
e 82301-03.04
The inspectors observed the emergency operations facility's staff as they performed
tasks in response to the exercise.
These tasks included facility activation,
notification of state and local response
agencies,
development
and issuance of
protective action recommendations,
dose assessment
and coordination of field
monitoring teams, and direct interactions with offsite agency response
teams.
The
inspectors reviewed applicable emergency
plan sections, departmental
procedures,-
instructional guides, logs, checklists, forms, and dose projections generated
during
the exercise.
Observations
and Findin s
The emergency operations facility was promptly activated.
Emergency operations
facility personnel
arrived shortly after the 8:55 a.m. alert declaration.
Upon arrival,
personnel
signed-in on the staffing board (only key positions), implemented position-
-14-
specific activation checklists, verified telephone
operability, and synchronized
facility clocks.
Full facility activation occurred at 9:25 a.m., followed by a
responsibility turnover with the satellite technical support center.
Notifications to offsite agencies were not always conducted satisfactorily.
Timely
and correct notifications were made to both the state and county officials using the
notification alert network following the site area and general emergency
declarations.
However, both state and county officials were not notified of an
upgrade
in protective action recommendations
via initial notification or a followup
message.
Applicable requirements
and supporting information are as follows:
Planning Standard
10 CFR 50.47(b)(5) states,
in part, "Procedures
have been
established for notification, by the licensee, of state and local response
organizations
and for notification of emergency personnel by all
organizations; the content of initial and followup messages
to response
organizations
and the public has be'en established;"
Appendix E.IV.D.1 states, "Administrative and physical means for notifying
local, state, and federal officials and agencies
and agreements
reached with
these officials and agencies for the prompt notification of the public and for
public evacuation
or other protective measures,
should they become
necessary,
shall be described."
Section 6.3 of the emergency
plan stated that, "The Emergency Coordinator
ensures that initial notifications are made to state and county warning points
and NRC in accordance with established
procedures.
The procedures
include
a means of message
verification. The initial notifications to state and county
warning points are initiated within 15 minutes of the declaration of an
emergency
and occur over the Notification Alert Network dedicated
telephone circuit (NAN)."
Section 6.3 further stated that, "... all subsequent
notifications are made
from the EOF [emergency operations facility] by the Government Liaison.
Initial notifications and followup messages
contain specific information about
the type and classification of the emergency
and whether emergency actions
are needed."
Section 6.6 of the emergency
plan stated that, "The Emergency Operations
Director (or Emergency Coordinator as appropriate) will make protective
action recommendations
.for the general public to offsite emergency
management
agencies."
Section 2.0 of 16DP-OEP17, "Emergency Operations Facility Actions,"
Revision 3, stated that the emergency operations director (in the emergency
operations facility) is responsible for, "Notification to state and county
agencies
regarding recommended
protective actions."
-15-
Section 1.0, "Noteworthy Items," of 16IG-OEP053, "Emergency Message
Forms," Revision 2, stated that, "Notifications to offsite agencies
shall
commence within 15 minutes following initial, upgraded,
or downgraded
emergency declarations."
Changes
in protective action recommendations
were not specifically addressed.
~
Section 2.0 of 16IG-OEP053 described the use of Form EP-0541, "Palo
Verde NAN Emergency Message" for making initial notifications.
Section 3.0 of 16IG-OEP053 stated that, "Form EP-0542, Follow-up
Emergency Message,"
is to be completed after initial notifications have been
made and as soon as time permits.
It should be prepared when information
becomes
available and transmitted to the Arizona Radiation Regulatory
Agency when requested."
~
Section 2.0 of 16IG-OEP053 instructs users to "Conduct notifications to
offsite agencies
using the appropriate action as determined by the following
flowchart:" The flowchart indicates that the notification alert network is to
be used if operational.
~
Notifications via the notification alert network include the following agencies:
Maricopa county sheriff's office, Arizona department of Public Safety,
Arizona Radiation Regulatory Agency, Arizona Division of Emergency
Management,
and Maricopa county Division of Emergency Management.
~
At 1:18 p.m., the emergency operations director upgraded the protective
action recommendations
to a 5-mile radius evacuation
and a 10-mile
evacuation
in Sectors G, H, and J.
There was no change
in emergency
classification status since a general emergency
had already been declared
at 11:30 a.m.
The emergency operations director quickly informed the
state director of operations of the protective action recommendation
changes
via a separate
direct line; however, county and other state agencies were not
provided the same information since the notification did not occur over the
notification alert network.
Moreover, neither an initial (Form EP-0541) nor a
followup (Form EP-0542) form was completed to document the protective
action recommendation
change.
In fact, no followup messages
were
prepared during the entire exercise.
In response to this issue, the licensee stated that there was no impact since the
"decisionmaker" was notified and that emergency
plan Figure 9 (a flowchart)
showed
a path from the emergency operations facility to the state director of
operations.
The inspectors acknowledged that informing the decisionmaker may
have lessened
the impact; however, delays in protective action implementation
could have occurred because
those responsible for implementation did not have
prior knowledge of conditions that warranted additional actions.
-16-
On June
11 and 12, 1997, the licensee informed the inspection team leader that
state and county officials concurred with the communication pro'cess used during
the exercise.
In addition, licensee personnel indicated that state and county
officials determined that the licensee met the "intent" of its emergency plan.
The inspectors determined that instructional guides for satellite technical support
center and emergency operations facility personnel did not provide clear guidance
concerning the need and method to be used to notify offsite agencies
of changes
in
protective action recommendations
or release status if changes
occurred without a
corresponding
change
in emergency classification.
Moreover, the emergency
plan
appeared
internally inconsistent
and that if the intent of the emergency
plan was to
provide for an altered notification/communication path after emergency operations
facility activation, the altered path was not clearly described
in the emergency
plan
and procedures.
Based on the above information, the inspectors concluded that the licensee failed to
notify state and county emergency management
agencies of a change in protective
action recommendations
as required by the emergency
plan,, departmental
procedures,
and instructional guides.
As a result, protective action decisions and
implementation could have been delayed since all responsible
parties were not
informed.
Since the demonstrated
level of preparedness
(performance
and
procedural guidance) were not satisfactory, the failure to notify state and county
emergency management
agencies of a change
in protective action recommendations
was identified as an exercise weakness
(50-528;-529;-530/9710-02).
Although command and control in the emergency operations facility were
satisfactory, communications
and information control were not always effective.
The following examples were observed:
Facility briefings were not conducted
in a manner that would allow
input/discussion from other facility members.
In most cases, the briefings
ended when the emergency operations director turned off the microphone.
Input from other facility members, such as the administrative and logistics
coordinator, technical analysis manager,
and security coordinator, was not
solicited so that it could be presented
for the entire facility to hear.
As a
result, important information may not have been shared with others who
may have needed the information, or inaccurate information could have been
kept within functional areas.
The radiological assessment
coordinator did
provide input on two occasions.
Three-part communications were not frequently used outside the dose
assessment
area and may have contributed to some information errors.
There was some confusion regarding the notification of unusual event
classification time. The event was announced
over the public address
at 8:45 a.m.; however, the event was actually declared at 8:34 a.m.
Due
-1 7-
to the confusion, an incorrect classification time (8:45 a.m., instead of
8:34 a.m.) was initially communicated to the state technical operations
center and, at 10 a.m., the assistant
emergency operations facility director
approved
a draft press release with the incorrect classification time.
~
The 11:33 a.m. event chronology board entry indicated that the utility's
protective action recommendation
was to evacuate
a 2-mile radius and
shelter Sectors J, H, and G to 5 miles.
The recommendation
was to
evacuate
Sectors J, H, and G, not shelter.
Apparently, the board was not
reviewed for accuracy.
The error could have led to confusion during event
reconstruction.
~
The radiation exposure units rem and millirem were not always clearly
communicated
or understood.
~
Some communications
between the NRC control cell and the emergency
operations facility were unnecessary
and may not be appropriate
in a real
emergency.
Section 7.0 of 16DP-OEP17,
"Emergency Operations Facility
Actions," Revision 3, stated that, if requested,
the government liaison was
to inform NRC Headquarters
of emergency operations facility activation.
The
government liaison made the call even though the request was not made;
however, the proper route for this information would be via the emergency
notification system (established
in the technical support center).
In an actual
emergency,
a continuous open line would be maintained with the NRC.
Separate
incoming calls would be a distraction.
The radiological assessment
coordinator exhibited good command and control of the
dose assessment
area.
The radiological assessment
coordinator briefed the team on
the initiating conditions and current event status and directed the dose assessment
health physicist to perform dose assessment
calculations based
on current and
default plant parameters.
The dose assessment
health physicist was very knowledgeable
in performing dose
assessments
and kept the radiological assessment
coordinator well informed of
changes
in radiological and meteorological conditions.
The radiological assessment
coordinator had frequent discussions with the emergency operations director about
the radiological status of the event, plant conditions, and protective action
recommendations.
While dose assessments
were generally good, the team did not discuss the validity
of using a 2-hour default release duration time, even when the duration of the
release exceeded
2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />.
The use of a release duration time estimate based on
actual plant conditions is crucial in determining accurate protective action
recommendations.
This matter was not identified as an exercise weakness
because
protective action recommendations
were not affected in this case (evacuation to
10 miles had already been recommended).
-1 8-
Additionally, some dose projection forms were incomplete and lacked detail.
For
example, some forms did not contain dose projection information out to 10 miles
and the protective action recommendation
did not contain specific information about
the area, radius, or specific sectors to be evacuated
or sheltered.
However, this
lack of detail did not prevent the emergency operations director from correctly
communicating the appropriate protective action recommendations.
Since the plant radiation effluent monitors were disabled during the event, resulting
in an unmonitored release, radiological information for the event came from field
survey teams (utility and state).
Communication between the licensee's
radiological
assessment
communicator and the field teams was generally good.
However, on
one occasion, radiation data from a team were incorrectly interpreted.
The apparent
error prompted the general emergency declaration.
In addition,
a significant amount
of effort was expended to determine the actual meaning of the data.
The field teams were effectively positioned in the down wind direction to measure
radiological releases.
The inspectors noted good cooperation
and teamwork
between the licensee's
radiological assessment
personnel
and state personnel.
Radiological field assessment
teams were properly tracked and coordinated
throughout the exercise.
In general, visual aids, such as maps and status boards, were not effectively used
by the dose assessment
team during the exercise.
The inspectors noted that the
field team tracking board was not used to post information about the field teams;
only meteorological data was posted.
The radiological status board was not used
for its intended data during the exercise.
Also, the meteorological data posted on
the status board near the main emergency operations facility status board was not
always in agreement with the data posted in the dose assessment
area.
The radiation protection support technician routinely performed effective habitability
surveys of the emergency operations facility and other surveys as directed by the
radiological assessment
coordinator.
A contamination control point was
established,
as was an area for dosimeter issuance.
Conclusions
Overall, the emergency operations facility staff's performance was generally good.
Offsite protective action recommendations
were developed
in a timely manner.
Less than satisfactory performance was observed
in the area of offsite agency
notifications.
An exercise weakness
was identified for a failure to notify offsite
agencies of a protective action recommendation
upgrade.
Communications
and
-1 9-
information control were not always effective.
Dose assessment
and field team
control activities were generally good.
Default values used in dose projections were
not always accurate
and could have negatively affected protective action
recommendations.
Communications with field teams and dose assessment
form
completion were inconsistent.
Interactions with offsite agency representatives
were
effective.
P4.6
Scenario and Exercise Control
a.
Ins ection Sco
e 82301 and 82302
The inspectors evaluated the exercise to assess
the challenge and realism of the
scenario and exercise control,
b.
Observations
and Findin s
The licensee submitted the exercise scenario for NRC review on March 21, 1997, to
meet the 60-day goal specified in Inspection Procedure 82302, "Review of Exercise
Objectives and Scenarios for Power Reactors."
The results of the NRC's review
were documented
in an April 24, 1997, letter to the licensee.
As indicated in the
April 24, 1997, letter, both the NRC and the Federal Emergency Management
Agency determined that the scenario was minimally challenging and was not
acceptable to meet exercise objectives.
Moreover, the scenario package submitted
to the NRC was incomplete.
In response,
the licensee revised the scenario and
submitted
a complete scenario package
on April 25, 1997.
The final scenario was
sufficiently challenging to test emergency response
capabilities and demonstrate
exercise objectives.
The following aspects of exercise conduct and control detracted from the realism
and training value of the exercise and were considered
areas for improvement:
Emergency notification system communicators were not required to maintain
an open line of communication with the NRC control cell and were
improperly allowed to perform other support functions.
In reality, this
individual would have been unavailable due to the need to maintain a
continuous open line with the NRC.
One exercise participant responded to the operations support center before
the notification of unusual event was declared.
The individual read
procedures
prior to activation.
Exercise participants collected air samples
as directed; however, there were
occasions when no attempt was made to count the sample media.
-20-
A controller gave emergency ventilation system monitor (RU-13B) data to a
radiation protection support technician who did not demonstrate
the
procedure to obtain the data.
Late in the exercise,
an unexpected
(incorrect) reading of 8 million millirem
per hour on a radiation monitor caused
repair tasks to be aborted and
additional assessment
concerns.
c.
Conclusions
The initially submitted scenario appeared
minimally challenging, and the package
was incomplete.
The inspectors determined that the final exercise scenario was
sufficiently challenging to test emergency response
capabilities and demonstrate
onsite exercise objectives.
Exercise control was sufficient.
Some activities were
over-simulated.
P4.7
Licensee Self Criti ue
a.
Ins ection Sco
e 82301-03.13
The inspectors observed
and evaluated the licensee's post-exercise
facility critiques
and the formal management
critique on May 23, 1997, to determine whether the
process would identify and characterize weak or deficient areas in need of
corrective action,
b.
Observations
and Findin s
Post-exercise
critiques in the control room/simulator, operations support center, and
emergency operations facility were not fully effective.
The critiques were generally
positive (not self-critical) and did not include input from exercise participants.
Although critique forms were available in all facilities for participants to document
comments, participant input was not solicited during the post-exercise
critiques to
actualize performance improvements prior to initiation of formal corrective actions.
The post-exercise
critique in the technical support center was conducted
in a
systematic manner and input was solicited from controllers and exercise
participants.
During the May 23, 1997, management
critique, the Department Leader, Emergency
Planning, presented
a compilation of comments from controllers and evaluators.
The licensee had not completed.its evaluation to determine the significance of the
comments (exercise weaknesses,
areas for improvement, etc.).
The management
critique tended to focus on strengths
and positive comments, rather than
describing/discussing
areas in need of improvement.
The issue involving the
untimely notification of unusual event declaration was described
as a scenario
development matter, as opposed to a performance matter.
The inspectors
concluded that the management
critique was not self critical.
-21-
c.
Conclusions
The critique process was not fully effective in identifying issues in need of
corrective action and areas for improvement.
With the exception of the technical
'support center, the post-exercise
facility critiques did not include input from
exercise participants.
The post-exercise
and management
critiques tended to focus
on strengths
and positive observations.
V. Mana ement Meetin
s
X1
Exit Meeting Summary
The inspectors presented
the inspection results to members of licensee management
at the
conclusion of the inspection on May 23, 1997.
The licensee acknowledged
the facts
presented.
No proprietary information was identified.
The licensee provided additional
information concerning the inspection findings during June
11 and 12, 1997, telephone
conversations.
On June 13, 1997, the licensee was informed that the issue involving
continuous accountability in the technical support center was no longer characterized
as an
exercise weakness.
ATTACHMENT
SUPPLEMENTAL INFORMATION
PARTIAL LIST OF PERSONS CONTACTED
Licensee
J. Levine', Senior Vice President,
Nuclear
T. Barsuk, Senior Emergency Planning Coordinator
H. Bieling, Department Leader, Emergency Planning
C. Bolle, Emergency Planning Coordinator
G. Cerkas, Emergency Planning Coordinator
R. Fullmer, Director, Nuclear Assurance
L. Houghtby, Assistant to Vice President,
Nuclear Engineering
A. Krainik, Department Leader, Nuclear Regulatory Affairs
D. Larkin, Senior Engineer, Nuclear Regulatory Affairs
B. Lee, Emergency Planning Coordinator
H. Lines, Emergency Planning Coordinator
D. Marks, Section Leader, Nuclear Regulatory Affairs
R. Nunez, Department Leader, Operations Training
M. O'Neal, Emergency Planning Coordinator
G. Overbeck, Vice President,
Nuclear Production
M. Pioggia, Emergency Planning Coordinator
J. Proctor, Shift Supervisor, Unit 1 Operations
T. Radke, Director, Outage 5 Scheduling
C. Seaman,
Director, Emergency Services
LIST OF INSPECTION PROCEDURES USED
Evaluation of Exercises at Power Reactors
Review of Exercise Objectives and Scenarios for Power Reactors
LIST OF ITEMS OPENED
~Oened
50-528;-529;-530/97010-01
IFI
Exercise weakness
- Failure to recognize and
classify the notification of unusual event
(Section P4.2)
50-528;-529;-530/97010-02
IFI
.
Exercise weakness
- Failure to make required
offsite agency notifications
tSection P4.5)
-2-
LIST OF DOCUMENTS REVIEWED
De artmental Procedures
and Instructional Guides
~
1 6DP-OEP1 3
1 6DP-OEP1 5
1 6DP-OEP1 6
1 6DP-'OEP1 7
16IG-OEP03 'I
16IG-OEP051
1 6I6-OEP1 61
Emergency Classification
Satellite Technical Support Center Actions
Technical Support Center Actions
Operations Support Center Actions
Emergency Operations Facility Actions
Assembly
Core Damage Assessment
Dose Projections
.,
Emergency Exposures
and Potassium
Iodide
Emergency Message
Forms
Protective Actions
Revision 0
Revision
1
Revision 4
Revision
1
Revision 3
Revision
1
Revision
'I
Revision 0
Revision 0
Revision 2
Revision
1
Other Documents
Palo Verde Nuclear Generating Station Emergency Plan
Revision 18
)
i
P
f
1
k
I