ML19275A961
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| Issue date: | 10/31/1979 |
| From: | PRESIDENT'S COMMISSION ON THE ACCIDENT AT THREE MILE |
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TECHNICAL STAFF ANALYSIS REPORT ON SELECTION, TRAINING, QUALIFICATION, AND LICENSING OF THREE MILE ISLAND REACTOR OPERATING PERSONNEL TO PRESIDENT'S COMMISSION ON THE ACCIDEV?.lT THREE MILE ISLAND ADVANCE COPY NOT FOR PUBLIC RELEASE T*rORE AMs, WEDNESDAY, OCTOBER 31, 1979 o
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1183 101 7 9103102yp
SELECTION, TRAINING, QUALIFICATION, AND LICENSING OF THREE MILE ISLAND REACTOR OPERATING PERSONNEL BY RONALD EYTCHISON TECHNICAL ASSESSMENT TASK FORCE e
OCTOBER 1979 WASHINGTON, D.C.
1t85 102
4 This document is solely the work of the Commission staff and does not necessarily represent the views of the President's Commission or any member of the Commission.
This pre-publication copy is a final document and will be N
subject only to minor editorial changes in its published form.
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I
SUMMARY
II INTRODUCTION III ACRONYMS, ABBREVIATIONS, DEFINITIONS IV TABLE OF CONTENTS V
ANALYSIS OF SELECTION, TRAINING, QUALIFICATION, LICENSING AND STAFFING VI FINDINGS VII APPENDICES e
m 1183 104 1
I Sl'MMARY As a part of the effort to identify and evaluate the possible causes of the Three Mile Island accident, an analysis of operator training, qualification, licensing, selection, and manning war conducted by the staff. The study included review of documents, interviews, and depositions at Three Mile Island, Babcock & Wilcox and the Nuclear Regulatory Commission (NRC) during June, July, and August 1979.
Analysis of the information obtained was conducted almost exclusively by the writer.
This paper examines the roles of the actors involved in training and it reviews the various programs which were intended to staf f Three Mile Island with sufficient numbers of competent, trained operators and supervisors. The analysis includes a review of the regulations concerning operator training and licensing, describes how the requirements were J'
implemented by the NRC, Metropolitan Edison, and Babcock & Wilcox, and then evaluates the programs conducted by these three organizations.
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Perhaps the most significant feature of the regulations is that
,j p' there is no regulation regarding operator selection and training; the NRC has no minimum eligibility standards for the qualification of M. ;
operators. Rather, the NRC endorses a standard established by the
.-f
'D American Nuclear Society (ANS) pertaining to the selection and training of nuclear power plant personnel. This standard (ANSI 18.1-1971)
..e.
includes recommendations to the utility concerning selection, training, and qualifications. Reactor operator candidates do not have to meet any h.
requirements concerning minimum education, experience, reliability, i
criminal record, or stress fitness.
}
With regard to reactor operator licensing, the regulations require f
that licensing examinations include questions on construction, design features, operating characteristics, and procedures. There is a lack of emphasis on the comprehensive knowledge of theory, principles of operation, kinetics, thermodynamics, and so on, which would enable operators to correctly interpret information available to them in the control room. Review of typical examination contents indicates the examinations are consistent with the regulations; they do not ensure that license candidates have an in-depth knowledge of nuclear reactor theory, design, and operation.
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2
i The NRC's involvement in operator training was perhaps limited by a shortage of resources in the Operator Licensing Branch (0LB). This group was understaffed and had to utilize examiners without reactor operating experience. Overall, the NRC did not cause a sufficiently comprehensive understanding of reactor plant design and operation by those persons who are licensed to operate the reactors or supervise their operation.
The Babcock & Wilcox Company had a crucial role in the training of Three Mile Island reactor operators. Because Met Ed did not have its own simulator, B&W, under contract, provided the only practical training given to Three Mile Island operators in operating and emergency procedures.
Despite the importance of B&W training, neither the company management, plant designers, nor other engineers had significant influence on the content of training courses or the manner in which they were conducted.
Few engineers at B&W, in fact, had first-hand experience in nuclear reactor operations.
Review of the curricula at Babcock & Wilcox indicates that, in general, the simulator training courses lacked depth. Evolutions and drills in the simulator were relatively simple.
Casualties involved single failures and were carried only through the immediate action rather than to their logical conclusions. The trainees did not function as a crew and no one was in overall charge.
Operators at the Davis Besse-1 plant experienced a transient on September 24, 1977, similar to that which later confronted operators at Three Mile Island. They interpreted parameters and took actions similar to their Met Ed counterparts. Significantly, the Davis-Besse operators realized that they were mistaken in sufficient time to avoid core damage.
The lessons of Davis-Besse and the potential hazards of that transient were recognized by Babcock & Wilcox Nuclear Power Generating Divisicn (NPGD) managers who were in a position to convey these lessons to utilities and incorporate the lessons into the B&W simulator training program. This was not done before the TMI accident.
Review of training conducted at B&W indicates that the manner in which the plant would be expected to respond to a small-break loss-of-coolant accident from the steam space of the pressurizer was not included in operator training. In fact, the simulator was unable to reproduce a transient of the nature of that which occurred at TMI-2 because it could not simulate voiding in the coolant system outside the pressurizer.
Students were not taught about saturation conditions in the reactor coolant system. The principle of keeping the core covered was not specifically treated in the training program.
Babcock & Wilcox did not instruct trainees one way or the other about allowing the pressurizer to go solid when the reactor is shut down.
'The success rate of TMI operators on NRC licensing examinations has been better than average, suggesting an above-average training program.
However, training received by operators at TMI did not prepare them sufficiently to cope with the March 2d transient. Underlying this was
'.nsufficient Training Department staffing and the lack of managemeat involvement in operator training.
Members of the training department were no more qualified educationally than the trainees.
)185 106
The replacement operator program which prepsred reactor operator candidates for licensing was done essentially on a self-study basis.
Although 9 months were devoted to this program, little emphasis was given to theory, application of theoretical to the practical, or the principles of operating and casualty procedures. Required study did not cover thermodynamics and such concepts as saturation, enthalpy, decay heat production, or solid system operation. Rather, emphasis was on systems, equipment, and procedures. Operator trainees were not provided with a fundamental, comprehensive understanding of their reactor plant design and operation which would enable them to recognize the significance of a set of circumstances not explicitly predicted by the operating procedures and which would lead them to place the plant in a safe condition.
Similar weaknesses were noted in the operator requalificatien program. Material was not treated in depth.
Lectures covered did not fulfill the requirements of the Met Ed administrative procedure on requalification. An average of only about one hour per week was devoted to lectures on topics related to reactor operation. Again, there was a lack of instruction which would enable operators to understand the significance of reactor plant phenomena.
With respect to training specifically related to the accident, there is no evidence that operators were taught concerning pressurizer level versus reactor coolant system (RSC) pressure.
Instruction did not adequately cover recognition of a loss-of-coolant accident, saturation conditions, the need to remove decay heat, or the significance of high temperatures and pressures in the reactor building.
Fundamental problems related to the training and licensing of Three Mile Island operators might be highlighted as follows:
There was a gulf between the operators or operationally-oriented personnel and the managers or other decision makers in the NRC, at Met Ed, and at Babcock & Wilcox. Few communications took place between Babcock & Wilcox management / engineering and simulator instructors. The NRC Operator Licensing Branch, which set and enforced the standards for operator training, was understaffed and lacked outside direction.
Three Mile Island management did not consider itself responsible for a
operator training.
The training standard was low and did not require that the operators be provided with the analytical tools necessary to operate a nuclear reactor.
There was no effective mechanism for learning from the mistakes of others. The, system was such that, in large part, the utilities had to learn for themselves. Quite probably, the accident at Three Mile Island would not have occurred if the operators had been thoroughly and comprehensively trained on the le'ssons of Davis-Besse.
There was no effective mechanism for ensuring a high level of knowledge. No competent outside organizatica periodically determined in-depth operator knowledge nor did the licensing 4
1183 107
and requalification process accomplish this. Unless the utility was enlightened and had the resources to ensure its own high standard then its operators might attain only mediocre know) :lge and skill.
There was no consideration given to training engineers at a higher level than the reactor operators. This stemmed, perhaps, from the underlying assumption that a nuclear reactor which produces power from a highly complex process and has the potential for affecting the health and welfare of the public can be operated solely by a few high school graduates or
" equivalent."
The safe, efficient production of electricity by a nuclear reactor
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plant requires adequate numbers of properly trained and qualified operators in control. But if the operators are not properly trained and qualified then safe operation must depend on the plant design alone. Technology has not reached the point where the operator could be eliminated; therefore, training, qualification and adequate staffing are essential to public safet) and efficient electrical generation.
e 5
II INTRODUCTION There is evidence that action or inaction of operators, in the face of symptoms which indicated a loss of coolant, core uncovering, and high temperatures in the core and then core damage, failed to place the plant in a safe condition and did not isolate radioactivity from the eniironment.
By the same token, managers who were apprised of the same symptoms did not understand their significance. Many actions taken may have exacerbated rather than mitigated the accident. These circumstances suggest that neither the operators nor their supervisors recognized what the symptoms indicated and did not understand the effects of many of their actions.
If the events which took place in the TMI-2 control room were not the result of malfeasance, and there is no evidence to suggest that they were, then it can be reasonably postulated that the root cause for operator errors was inadequate training.
The purpose of this paper is to examine the selection, training, qualification, and licensing of operators in some detail. The term
" operator" should be understood to include all those persons involved in reactor operation including nonlicensed operators, reactor operators, supervisors, engineers, and managers. The basic approach will be to list the requirements, describe how these requirements were implemented, and then evaluate the results in terms of the implementing programs.
The nonexistence of needed requirements also will be discussed.
Preparation of this paper involved examination of many documents of both a prescriptive and descriptive nature, records of training conducted by Babcock & Wilcox and Met Ed as well as NRC Operator Licensing Branch recordr.. Every available record pertinent to this area and known to the investigator was reviewed.
Interviews of Babcock & Wilcox Company Training Services personnel were conducted on June 19-20, 1979. This was followed up by deposition of the same persons between July 3-6, 1979. Met Ed Training Department members were interviewed June 26-27, with depositions being taken July 27-31.
NRC Operator Licensing Branch interviews and depositions took place on July 23 and July 28 respectively.
All interviewees and deponents were very helpful. Requested documents were promptly produced by the organization from which they were sought.
No particular difficulties were encountered in this investigation.
1183 109 6
III ACRONYMS AND ABBREVIATIONS AEC Atomic Energy Commission ANS American Nuclear Society ANSI American National Standards Institute A0 auxiliary operator AP administrative procedure B&W Babcock & Wilcox Company CFR Code of Federal Regulations Davis-Bessee Davis-Besse Nuclear Generating Station, Toledo, Ohio EP emergency procedure FSAR Final Safety Analysis Review FSR Fundamentals and System Review Program GA0 General Accounting Office GPU General Public Utilities Corporation HP health physics HPI High Pressure Injection ICS Integrated Control System I&E Office of Inspection and Enforcement (NRC)
LER Licensee Event Report LOCA Loss-of-Coolant accident Met Ed Metropolitan Edison Company NRC Nuclear Regulatory Commission Oconee Oconee Nuclear Station, Clemson, South Carolina OJT On-the-job training
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OP operating procedure OR Operational Review Series OTSG Once Through Steam Generator PORV Pilot-0perated Relief Valve RCS Reactor Coolant System R0 Reactor Operator SER Safety Evaluation Report SFAS Safety Features Actuation System SRO senior reactor operator
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IV TABLE OF CONTENTS FOR ANALYSIS OF SELECTION, TRAINING, AND LICENSING OF THREE MILE ISLAND REACTOR OPERATING PERSONNEL A.
Requirements B.
Implementation of Requirements 1.
Nuclear Regulatory Commission 2.
Metropolitan Edison Program a.
General b.
Auxiliary Operators c.
" Cold" License Training Program d.
" Hot" License Training Program e.
Shift Foreman Training and C'rtification e
f.
Shift Supervisor Training and Certification g.
Requalification Program 3.
Babcock & Wilcox Program a.
New Plant Operator Training b.
Replacement Operator Training c.
Simulator Requalification Training d.
Facilities and Equipment i183 111 8
C.
Evaluation of Operator Selection, Training, Licensing, and Staffing 1.
Nuclear Regulatory Commission Requirements and Implementing Procedures a.
b.
Operator Eligibility and Selection c.
Training d.
Operator Examinations and Tests e.
License Issuance f.
Requalification 2.
Babcock & Wilcox c.
Training Services Staffing and Organization b.
Management / Engineering Role c.
Training Contract d.
Course Administration e.
Simulator Training f.
Training Related to LOCA g.
Courses taken by TMI Personnel 3.
Three Mile Island Training Department Staffing and Organization a.
b.
Management and Training c.
Evaluation of Training Program (1) General (2) General Employee Training (3) Auxiliary Operator Training (4) Replacement Operator Training (5) Senior Reactor Operator Training (6) Requalification (a) OR Series On-the-Job Trai_ing1 1 8 3 1 1 2 (b) 9
(c) Annual Evaluation Examination d.
Specific Training Deficiencies Related to the Accident (i) Pressurizer Level versus Reactor Coolant System Pressure (2) Failure to Recognize a Loss-of-Coolant Accident (3) Failure to Recognize that the Plant Was at Saturation (4) Lack of Understanding of Need to Remove Heat (5) Failure to Recognize the Significance of Radiation Levels in the Reactor Building f.
Summaries of Individual Qualifications 1183 113 10
VI ANALYSIS OF SELECTION, TRAINING.
QUALIFICATION, LICENSING, AND STAFFING REQUIREMENTS FOR SELECTION, TRAINING, LICENSING, AND STAFFING OF REACTOR OPERATING PERSONNEL The Atomic Energy Act of 1954 established the requirement that all persons who operate nongovernment-owned nuclear reactors must be licensed.
Section 107 of the act established a requirement that uniform conditions for licensing individuals as operators be prescribed.
In addition, the Atomic Energy Commission (AEC) was required to determine the qualifications of such persons and issue licenses to individuals in such form as the Commission may prescribe.
Title 10, Chapter 1, Part 50 of the Code of Federal Regulations (10 CFR 50), Licensing of Production and Utilization Facilities, paragraph 50.34(b)(6)(i), requires that the application for a license to operate a facility include information concerning the " applicant's organizational structure, allocation of responsibilities and authorities, and personnel qualifications requirements." Part 50 requires that the liccusee not permit manipulation of the reactor 7 ntr is by anyone who is not a licensed operator or senior operator.1 Additionally, Part 50 requires Within three (3) months after issuance of an operating license, the licensee shall have in effect an operator requalification program which shall, as a minimum, meet the requirements of Appendix A of Part 55 of this Chapter.
Notwithstanding the provisions of 150.59 the licensee shall not, except as specifically authorized by the Commission, make a change in an approved operator requalification program by which the scope, time allotted for the program or frequency in conducting different parts of the program is decreased. [/
Finally, part 50 requires that apparatus and mechanisms other than controls which may affect the reactivity or power level shall be manipulated only with the knowledge and consent of a licensed operator. An operator or senior operator must be present at the controls at all times during facility operation and a senior operator must be present during operation 11 1183 114
or readily available on call. The senior operator is required to actually be present in the facility during certain specified plant conditions including recovery from an unplanned shutdown. 3/
The basic Nuclear Regulatory Commission regulation which implements the requirements of the Atomic Energy Act of 1954 is 10 CFR 55.
This regulation establishes procedures and criteria for the issuance of licenses to operators, including senior operators. With regard to the selection and training of persons to become operators, however, there is no regulation; the NRC has no minimum eligibility requirements for either operators or senior operators and has not prescribed any training standards for the qualification of operators. Rather, the NRC in a part of a regulatory guide to the nuclear industry, endorses standard established by the American Nuclear Society pertaining to selection and training of nuclear power plant personnel.
Regulatory Guide 1.8, Personnel Selection and Training, describes a method acceptable to the NRC staff of implementing the portion of the NRC's regulations (10 CFR 50) with regard to personnel qualifications.
Subcommittee ANS-3, Reactor Operations, of the American Nuclear Society Standards Committee developed a standard containing criteria for the selection and training of nuclear power plant personnel.
Subsequently, it was approved by the American National Standards Institute (ANSI)
Board of Standards Review and designated ANSI N18.1-1971, Selection and Training of Nuclear Power Plant Personnel. Regulatory Guide 1.8 states that the criteria for the selection and training of nuclear power plant personnel contained in ANSI 18.1-1971 are generally acceptable and, with one minor exception, 4/ provide an adequate basis for the selection and training of nuclear power plant personnel. As noted by GAO report, EMD-79-67, dated May 15, 1979, "the standard is intended as a guide and does not preclude anyone from not conforming to it."S]
Standard ANSI 18.1 - 1971 provides criteria for the selection and training of personnel for stationary nuclear power plants and addresses itself to the qualifications, responsibilities and training of both operating and support personnel. The standard includes the following recommendations:
that managers, supervisors, operators, technicians and repairmen have prescribed levels of education, experience, health, and skill; that desired experience may be gained through actual nuclear power plant operation, including military, nonpower plant nuclear experience, simulator training, training programs, or on-the-job training; that a training program be established and maintained to provide adequate numbers of fully trained and qualified operating, maintenance, professional, and, technical support personnel; that candidates for NRC cold examinations be qualified by a combination of experience and technical training; 15 12 4
that candidates for NRC hot examinations complete certain technical training, on-the-job training, practice startups and shutdowns, and programs of self-study and counseling; that a program be implemented for training personnel not requiring licenses; that retraining and replacement training be provided; 2
that minimum health requirements be established; and that minimum education and experience levels be established, as follows:
Operator:
High school diploma or equivalent and two years of power plant experience or its equivalent provided that a minimum of one year is at a nuclear power plant.
Senior operator:
high school diploma or equivalent and four years of responsible power plant experience. A maximum of 2 years of the remaining 3 years of power plant experience can be fulfilled by academic or related technical training on a one-for-one basis.
The plant manager shall have acquired the experience and train'ing normally required by the NRC for a senior reactor operator license whether or not the examination is taken. The operations manager shall hold a senior reactor operator license.
No other management personnel need hold licenses.
The standard remains silent with regard to reliability, stress fitness, psychological screening, and candidates' criminal records.
In January 1978, the American National Standards Institute approved Revision 1 to N18.1-1978. The revision provides more detailed guidance reflecting additional experience with staffing and training nuclear power plant personnel. Major changes concern the requirements for qualifications of operating personnel and expansion of the requirements of the training program for licensing and requalification and for general employee training.
In February 1979, a proposed Revision 2 to Regulatory Guide 1.8, which would recognize ANSI /ANS 3.1-1978, was issued for comment.
It was not expected at the time of issuance that implementation by the NRC staff would take place befort October 1979. The current status of ANSI /ANS 3.1-1978 is unclear. 6/
Specific requirements for TMI-2 are contained in the Safety Evaluation Report (SER), the Final Safety Analysis Report (FSAR), and the plant operating license.
The SER, Section 13.0, stated that a minimum shift would consist of at least five persons of which one would hold a senior operator license and two would be licensed operators. Overall training would be the responsibility of the TMI-2 plant superintendent. The program for training 13 1183 116
and qualification would conform to ANSI Standard 18.1-1971. The SER described a program by which TMI-1 supervisory personnel would obtain licenses for TMI-2 as well as a program by which reactor operators for TMI-2 would be selected from senior qualified auxiliary operators assigned to TMI-1 Finally, the SER stated that requalification training and replacement training would conform to 10 0FR 50, 10 CFR 55, Appendix A, and follow the guidance in ANSI 18.1.
The TM1-2 FSAR, Section 13.2, contains requirements for the staffing qualification and training of operators and members of the staff organization.
In particular, the FSAR requires a minimum shift composition during reactor operation of one senior operator, two operators, and two nonlicensed personnel. At least one licensed operator must be in the control room when fuel is in the reactor and at least two licensed operators must be present in the control room during reactor startup, shutdown, and during recovery from reactor trips. Each member of the unit staff shall meet or exceed the minimum qualifications of ANSI 18.1-1971 for comparable positions, except for the supervisor of radiation protection and chemistry, who shall meet or exceed the qualifications of Regulatory Guide 1.8.
A retraining and replacement training program for the unit staff shall be maintained under the direction of the director for generation training and shall meet or exceed the requirements and recommendations of ANSI 18.1-1971 and Appendix A of 10 CFR 55.
Section 13.2.2 of the FSAR describes in some detail the requirements for the Met Ed Operator Requalification Program. This program, which includes preplanned lectures, on-the-job training, annual evaluation examinations, and accelerated requalification for those requiring remedial work, is implemented by Administrative Procedure 1006 and is evaluated below.
IMPLEMENTATION OF REQUIREMENTS Nuclear Regulatory Commission Implementation of the requirements contained in 10 CFR 55 and Regulatory Guide 1.8 is the responsibility of the Operator Licensing Branch (0LB) of the Office of Nuclear Reactor Regulation. OLB is assisted in certain aspects of fulfilling these requirements by the Office of Inspection and Enforcement (I&E).
The chief, Operator Licensing Branch, reports to the assistant director of the Division of Project Management for Quality Assurance and Operations. The Division of Project Management, in turn, is a section of the Office of Nuclear Reactor Regulation. Thus, the OLB could be d scibed as a sixth echelon organization in the NRC with the following t-
- function:
Examines and licenses candidates for reactor operator and senior teactor operator license; develops qualification requirements, testing techniques, and standards for evaluation of candidates and conducts safety evaluation for design and operation of reactor projects. 7/
The Office of Inspection and Enforcement, through its regional, offices, is charged with conducting periodic inspections of nuclear 14
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reactor operating staff training.
Inspection objectives as described in chapter 4100 of the Inspection and Enforcement Manual are to:
confirm that the licensee has trained the operating staff; confirm that a continuing program of training is being conducted; and verify that replacements receive training or have the experience equivalent to that required for originally selected personnel.
This is accomplished by conducting a semi-annual spotcheck of the staff training program to include attending training sessions, lesson plan review, training record review, and interviews of selected individuals in various job classifications. The inspection should review the licensee's training program and gauge its adequacy vis-a-vis the guidance in ANSI 18.1-1971 and the requirements of the FSAR. Additionally, the inspector is required to review the licensee's qualification training program to verify t, hat it is being conducted in accordance with regulatory requirements.8/ However, the Operator Licensing Branch is responsible for reviewing the adequacy of the technical contents of written examinations administered to licensed operators during separate audits.
The principal document utilized by OLB for administering the requirements for cperator licensing (as distinguished from training) is the NRC Operator Licensing Guide (NUREG-0094). This guide describes the procedures and criteria for the issuance of operator and senior operator licenses and is intended to assist applicants and facility licenses better understand the pertinent provisions of the NRC regulations as they relate to operator licensing. Although the preface to the Licensing Guide emphasizes that compliance with its provisions is not required, the guidance is comprehensive and in some areas is even prescriptive. Therefore, its contents will be discussed in some detail.
NUREG-0094 consists of sections on how to prepare the license application, scheduling of examinations, conter~
.perator and senior operator written examinations, operating tests,
-a_ vers, operating tests before criticality, license expiration, renewal applications, and denial of applications. Appendices include sample medical history forms, typical sample written examination questions, procedures for examination
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with no reactor startup demonstration, and an oral examination checklist.
An application for license must include the education and pertinent experience of the applicant. Cert.#ication that he has completed training as required by the facility licensee and that he has competently and safely operated the controls must be included. Application certification should list details on the courses of instruction administered by the facility licensee including the number of course hours, hours of training, nature of the training, and startup and shutdown experience received.
Applicants must have manipulated the controls of the reactor through at least two reactor startups and participated in several other transients or have completed an approved training program using a simulator to meet the manipulation requirements.9/ The need for the applicant to be licensed must be justified.
118.3 118.
5
Written and. operating examinations are scheduled well in advance; applications should be submitted at least 2 months before the expected date of examination adminis'..ation. The topical content of the operator written examin~, tion is set forth in Section 55.21 of 10 CFR 55.
The 12 topics listed in 10 CFR 55 are rearranged by NUREG-0094 into seven categories for written examinations:
1.
Principles of Reactor Operation 2.
Features of Facility Design 3.
General Operating Characteristics 4.
Instruments and Controls 5.
Safety and Emergency Systems 6.
Standard and Emergency Operating Procedures 7.
' Radiation Control and Safety The senior operator written examination includes the following additional topics:
8.
Reactor Theory 9.
Radioactive Material Handling, Disposal, and Hazards 10.
Specific Operating Characteristics 11.
Fuel Handling and Core Parameters 12.
Administrative Procedures, Conditions, and Limitations Evaluation of the content of operator and senior operator written examinations expected by both 10 CFR 55 and NUREG-0094 indicates that an elementary rather than comprehensive level of knowledge of nuclear reactor theory, design, and operation is sufficient. There is an emphasis on memorizing numbers, on how parameters change, and on how manipulations are performed. With regard to standard and emergency operating procedures the operator is required to " demonstrate complete understanding of the symptoms, automatic actions and immediate action steps" 10/ but there is no indication he need understand the principles of the operating and emergency procedures. There is a fundamental lack of emphasis on applying the theoretical to the practical. Required examination content for operators does not include the demonstration of a comprehensive knowledge of the following:
plant materials, stress, brittle fracture reactor coolant system (RCS) chemist.
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secondary system chemistry reactor core thermodynamics overall plant thermodynamics emergency thermodynamics including decay heat, core cooling, and natural circulation saturation phenomena radiation theory hazards to the public including the amount of radioactivity which could be released and the potential consequences of such releases loose surface contamination airborne radioactivity personnel surveys and decontamination interrelationships between the secondary and primary systems emergency situations not covered by emergency procedures As a part of the licensing process,10 CFR 55 requires that the candidate be administered an operating test. Among other things, the applicant is required to conduct a reactor startup from shutdown to power. NUREG-0094, on the other hand, permits an alternative program, not recognized by the regulations.
If the applicant satisfactorily completes an NRC-approved training program consisting of a 500-hour lecture series on subjects listed in ANSI 18.1-1971 and a program of at least one week's duration at a nuclear power plant simulator, no actual reactor startup needs to be performed during the license examination. M/ This program was initiated because of the burden imposed on the utility of requiring an actual reactor startup. M/ The senior operator and operator operating tests are similar in scope. The senior operator need demonstrate a greater depth of knowledge but he is not intended to be nor is he tested as a supervisory reactor operator.
M/
If the applicant has had extensive actual operating experience at a comparable facility within 2 years prior to the date of application and has discharged his responsibilities competently and safely the h3C may waive any or all the requirements for a written examination and operating test provided that the facility licensee certifies that the applicant is qualified to operate the facility.
NUREG-0094 gives procedures for implementing the provisions of 10 CFR 55 concerning the administration of operating tests prior to initial criticality. These examinations are termed " cold" examinations as opposed to examinations given at an operating reactor, which are called " hot" examinations. A cold examination is given if there is an
.(
immediat.e need for the services of the operator or senior operator 17 11M 120
license applicant and the applicant has had extensive actual operating experience at a comparable reactor. NRC considers for this purpose that any light water power reactor is comparable to any other light water power reactor.
It also considers that completion of an NRC-approved simulator program is extensive actual operator experience.
NUREG-0094 also provides details of application denial and reapplication.
If an application is denied because of failure to pass the written examination, operating test or both, the applicant may reapply 2 months after the date of denial. A third application may be filed 6 months after the second denial. Subsequent applications may be submitted at 2-year intervals. 14/
Appendix E to the Operator Licensing Guide includes sample questions typical of those appearing in operator and senior operator written examinations.
Appendix G to the Operator Licensing Guide is a sample Examination Report (NRC Form 157) which serves principally as a checklist for the operating test.
Metropolitan Edison Program General. Training conducted at Three Mile Island is primarily intended to result in the successful completion of NRC licensing requirements for control room operators (CR0s) and senior reactor operators (SR0s) and then to ensure that the requalification program requirements of Appendix A to 10 CFR 55 are met.
Secondary objectives include providing training for persons not requiring licenses and general employee training as speified in ANSI 18.1-1971.
Training to ensure that candidates for NRC operator licenses are properly qualified includes auxiliary operator training and either
" cold" or " hot" operating licensing programs. The terms " cold" or " hot" refer to whether the license is being obtained prior to initial core fuel loading or subsequent to initial criticality. The training of replacement operators is also accomplished by means of the " hot" licensing training program. Operator proficiency and certification are maintained through the licensed operator requalification program and periodic examinations. The manner in which these programs are intended to be carried out follows.
The normal progression of qualification commences with Auxiliary Operator C and continues through Auxiliary Operator B and A.
An AO'C' operates equipment only under the supervision of a more senior operator.
A0'B's are permitted to operate secondary systems and equipment without supervision whereas an AO'A' is allowed to operate both primary and secondary equipment outside the control room. Auxiliary 9perator A can apply for (" bid on") the position of control room opera':. (CRO) trainee when such a position becomes vacant.
Licensed CR0s can compete for available senior reactor operator (SRO) positions.
Auxiliary Operators (A0s). The program for the training and qualification of auxiliary operators is not defined formally.
Consonant with the recommendations of ASI 18.1-1971 regarding qualification of nonlicensed operators, Metropolitan Edison requires all auxiliary operators to possess a high school diploma or equivalent with additional educational attainments for progressively higher levels.
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Auxiliary Operator C must have completed a course in algebra. They are required to attend a 9-week classroom training program which covers the following areas:
- Secondary plant systems Fundamentals of mechanics and heat transfer
- the basic steam cycle
- health physics
- switching and tagging procedures
- basics of safety features actuation system (SFAS)
- basics of reactor protection system (RPS) first aid fire fighting Upon completion of this initial training, A0'C's must pass a written examination. They are then assigned to a shift and work under the supervision of an AO' A' for the remainder of a year.
In order to become an A0'B', the A0'C' must pass another written and oral examination.
If he fails the examination he is removed from the training program.
At the A0'B' level trainees must have completed courses in high school physics and trigonometry. They are required to complete a 6-week classrocm program which is culminated by a written examination.
Topics included are:
- make-up system decay heat remo'cl core flood system reactor building cooling and spray study of the SFAS and the RPS nuclear instrument system
- control rod drive mechanisms integrated control systems advanced health physics For the remainder of the one-year period as an A0'B', the operator is engaged in on-the-job training under the supervision of a shif t foreman.
At the end of the year the trainee must pass both written and oral
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t
examinations in order to remain in the program and to be promoted to A0'A'.
Once promoted to A0'A' he is then eligible to become a control room operator trainee when such a position becomes available.
" Cold" License Training Program. As provided for in Section 5.2.1 of ANSI 18.1-1971 and Section 13.2 of the TMI-2 FSAR, Met Ed developed a program for " cold" licensing of the initial TMI-2 staff. This program was reviewed by the NRC Operator Licensing Branch for compliance with established standards and was formally approved. Section 13.0 of the Safety Evaluation Report (SER) concluded that the training program and schedules for TMI-2 staff members were acceptable for the pre-operational test program, for operator licensing examinations, and
~
for fuel loading. Although this was a one-time program for the purpose of ensuring properly trained and licensed operators would be at the controls for initial fuel loading and reactor startup, it is important that its significance be understood in the overall process of operator licensing. Therefore the " cold" licensing program for TMI-2 will be described briefly.
Met Ed's program for initial TMI-2 staff " cold" licensing was tailored to the needs of the reactor operators of TMI-2 who were to be selected from senior qualified auxiliary operators assigned to TMI-1.
Their training was to include approximately 200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> of classroom training, training in the differences between TMI-l and 2 and a one-week course at Penn State University on core physics and reactor startups.
One month was to be spent in observation training on Unit 1 and eight weeks training on the Babcock & Wilcox simulator. Finally, the program was to include both written and oral examinations similar in nature to those administered by the NRC for cold licensing purposes.
" Hot" License Training Program.
" Hot" license training is correctly referred to as replacement operator training. At TMI the program for preparing replacement operator candidates for " hot" licenses is known as the Category IV Training Program. The Category IV Program has not been sanctioned officially by means of an administrative procedure. Rather, the promulgating document was Training Department Administrative Memorandum Number Five, dated October 8, 1976. This memorandum was submitted to the station superintendent the unit superintendents and all department heads. M/
When an AO'A' bids on a control room operator position and is advanced to Category IV CRO, he will be placed in a 9-month training program consisting of specific study assignments, practical work, written tests, oral examinations, and classroom sessions. Throughout most of this period the individual will be on shift.
The replacement operator program is intended to provide in-depth coverage of all areas specified in ANSI 18.1-1971 and the TMI-2 FSAR, namely:
- reactor theory 1183 123 20
- features of facility design
- general operating characteristics
- instrumentation and control
- safety and emergency systems
- standard and emergency operating procedures
- radiation control and safety Administratively, the Category IV program is to be handled in the following fashion:
Upon being advanced to CR0, the individual will be assigned to a shift Two hours, as a minimum, of each day on shift will be specifically devotei to training.
The individual.411 be provided with a desk or other suitable place to study in the control room area. While on shift, the individual receives a series of preprogrammed written assignments.
He is administered written and oral examinations every 3 and 6 weeks respectively. Errors and weak areas on both written and oral exams will be reviewed with the individual; failure of a written exam or oral exam will be discussed with the individual and a retest will be administered on the material. Additionally, the CR0 will be required to complete a Practical Evolutions Sheet. This sheet will be completed either during his daily training period or during other times while on shift as situations dictate. Most of the items involve performing evolutions, simulating performing evolutions, and understanding and being able to explain while simulating or performing. The individual's shift supervisor, shift foreman, an SRO-licensed individual or the licensed training coordinator may sign the practical evolution sheet. Assignments on which written and oral tests will be giren will come largely from items on the Practical Evolution Sheet. Checkouts for items on the Practical Evolution Sheet which must be simulated will be conducted in front of the control room consoles and panels with the trainee being required to point to specific items and controls. The checkout must be satisfactory prior to a signature for the evolution. The evolutions are assigo-d a point value to track the progress of an individual through the program.
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To aid the individual in the training assignaent completion he may come of f shif t to attend lectures on specific topics, listed below, as determined by the supervisor of the Training Department and the supervisor of operations.
Area Du, ration Reactor Theory 1 day - I week ICS Review 1 day - I week Simulator 1 week or 2 weeks 16/
Health Physics Review 1 day - 1 week b.
2k 21
Refueling Review I day - I week These off-shift lectures are intended to aid the individual in obtaining signatures on the Practical Evolution Sheet. They are also the manner in which the trainee meets the requirement for 500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> of lectures specified in Appendix F to NUREG-0094.
The first 90 days of the CR0 training program are designated as a probationary period during which the individual will be evaluated. At the end of this 90-day period, the shif t supervisor, supervisor of operations, and the supervisor of training will reccamend whether or not the individual should continue in the program.
Prior to the completion of the 9-month period, the CR0 will be given a comprehensive written examination approved by the supervisor of operations and the supervisor of training and will receive a comprehensive oral examination by an SRO-licensed individual designated by the supervisor of operations.
If the CR0 has not successfully completed the program within 9 months or fails either the written or the oral examination, he will return to the position held prior to being advanced to CRO.
If the individual successfully completes the training program within 9 months and fails either the written or oral examination a re-examination will be considered based upon an evaluation by the supervisor of operations and the supervisor of training.
If the trainee successfully completes the training program within 9 months and passes the final comprehensive written and oral examinations he may be recommended for examination by the NRC and subsequent R0 licensing.
Shift Foreman Training and Certification. Certification as a senior reactor operator (SRO) is accomplished also by means of satisfactory completion of NRC examinations. Training leading to SR0 qualification is achieved through programs which, again, have not been officially
' established by means of an administrative directive.
The de facto training, qualification, and certification program is tailored to suit persons selected from one of three backgrounds:
individuals who had achieved and maintained SR0 licenses on TMI-1; individuals who had achieved SRO licenses on other facilities; or individuals selected from the initial group of TMI-2 control room operator trainees.
Training is expected to include formal classroom instruction, Babcock & Wilcox simulator training, in plant experience, and company-administered examinations in preparation for the NRC licensing examinations.
The details and relative emphasis will be varied not only within the three categories of backgrounds but also in individual cases.
Shif t Supervisor Training and Certification. Shift supervisors are required to be certified at the senior reactor operator (SRO) level for 22 118.5 125
both TMI-l and TMI-2 through satisfactory completion of NRC-approved examinations. For initial dual unit staffing a Cross License Training Program was administered to obtain FMI-2 SR0 licenses. Classroom, on-the-job, and simulator training were conducted. At the conclusion of the program, a mock NRC examination was administered with emphasis on TMI-2 systems and differences between the TMI-1 and TMI-2 nuclear steam supply systems, secondary, and balance of plant systems. The program documentation, exam, and exam results were forwarded to the NRC for approval. This culminated in persons already licensed in TMI-1 having their licenses amended to include TMI-2.
Subsequent to " cold" licensing, a " hot" license training program was developed by the Training Department to cross qualify SR0 license holders from either unit. Again, this program has not been officially defined.
It is intended to be a self-study course with periodic written and oral examinations to monitor the individual's progress. As in the
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case of the initial cross licensees this program culminates in a written examination administered by the Training Department.
The results are reviewed by the NRC and amendments to licenses issued to include the other unit.
Requalification Program. Pursuant to the requirement of Appendix A to 10 CFR 55 that each licensed operator demonstrate his continued competence, Met Ed established a Requalification Program by means of Administrative Procedure 1006. This procedure was submitted to the NRC as a portion of the FSAR.
The Met Ed Requalification Program consists of four interrelated segments which run concurrently. These are:
Operational Review Lecture Series (OR)
Fundamentals and System Review Program (FSR) on-the-job training (0JT) annual evaluation examinatior.s The OR series is a classroom lecture presentation which provides licensed personnel with the details of operational informati,cn. As a part of the OR series, FSR topics selected from areas of the annual written examinations in which operators had difficulty are given. OR lectures are scheduled for a minimum of 60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br /> per year. On-the-job training is intended to ensure all licensed persons operate the reactor controls and participate in major plant evolutions. Th,e annual evaluation examinations simulate the written and oral NRC examinations.
Performance on these annual evaluation examinations determines the extent of the FSR program during the following 12-month period. Each licensed operator must complete all OR and FSR requirements on an annual cycle. On-the-job training is conducted throughout the 2 year term of the individual's license. A statement of requalification program participation will be submitted with each license renewal application.
Operational Review (OR) Lect 6re Geries attendance is required of all licensed operators and senior operators on shif t assignments. The following topics will be covered as a minimum each year:
23 1183 126
reportable occurrences unit modifications operating history and problems procedure changes abnormal and emergency procedure review technical specifications major operational evolutions applicable portions of Title 10, Chapter I, CFR FSR program material Additional topics which may be covered include:
operational Q/A standing orders operating experiences, reactor safety, and pertinent NRC publications Absences will be made up by reviewing lecture materials and/or discussions with on-shift supervisors or technical ataff.
Periodic quizzes covering content of OR lectures will be administered.
The Fundamentals and Systems Review Program participation for licensed persons is based on their annual written examination scores.
The FSR program may consist of lectures, self-study, tutorial sessions, and quizzes.
On-the-job training ensures that each licensed operator (CR0 or SRO) participates in at least 10 reactivity manipulations, participates in applicable surveillance testing, system checkout and equipment operations, and reviews procedure changes, equipment modifications, and trchnical specification changes. Diversity of operations is required.
Licensed persennel, whose job assignments are not directly related to unit operations, will actively participate in control room operation 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> per year.
This may be performed in a simulator.
The annual written evaluation examination will be administered to all licensed operators and will simulate the NRC written examinations.
The annual oral examination will be administered to all licensed persons using a checklist; prescribed areas will be covered.
Persens scoring less than 80 percent on any section of the annual written examination will be required to attend the FSR program related to failed sections.
I183 127 24
Babcock & Wilcox The Babcock & Wilcox Training Services Section, a part of the Customer Services Department, provides training services to utility customers to assist in the training, qualification, and licensing of reactor operators and senior reactor operators and to train management personnel and engineers in the fundamentals of B&W designed nuclear steam supply systems (NSSS). Additionally, there are some specialized, highly technical courses available.
The Training Services Section does not have a formalized training program. Rather, the company offers a variety of individual training courses which the customer may contract for and which are desc-ibed only briefly in a Nuclear Training Services Catalog. These courses are as follows:
Course Number Course Title T101 Management Seminar T102 Basic Nuclear Orientation for Managers T103 Nucleae Power Plant Operations for Management T201 Engineering Staff Orientation T202 Plant Operations for Engineers T203 Physics Test Orientation for Engineers T301 New Plant Operator Program T302 NSS Orientation for Experienced Engineers and Operators n$3 128 25
T303 Replacement Operator Training T304 Simulator Requalification Training T401 Nuclear Plant Maintenance T402 Instrumentation, Control and Computer System Training T403 Chamistry Technician Training T501 NSS Videotape Seminar The most valuable service which B&W can provide is to offer " hands-on" training to operators and operator candidates in manipulating simulated reactor controls during ncrmal and emergency conditions.
As far as the NRC is concerned, the manipulation of controls and the simulation of emergency cr abnormal conditions may be accomplished by using the control panel of the facility or by using a simulator. Since the use of a simulator is encourr ged 17/ and because it is not practical to perform power level changes and casualty drills for training on an operating commercial power reactor, the B&W simulator is used extensively for operator training.
The most commonly used courses at B&W and the only courses contracted for by Met Ed for its operators are T301, T303, and T304. Only these will be described here. 18/
New Plant Operator Training / T301. This course provides utility personnel with the training necessary to become reactor plant operators.
The program has been certified by the NRC to meet all prerequisites for the " cold" license oocrators to support an initial plant startup. The complete program consists of five different courses designed as a package to fulfill current NRC " cold" license requirements.
Included are courses in basic nuclear theory (12 weeks), observation experience (8 weeks),
simulator operations (8 weeks), nuclear steam systems (4 weeks), and on-the-job training at the customer's site (10 months). The most commonly used course is the simulator operations course consisting of practical instruction on the full-scale B&W PWR simulator, related classroom instruction, and individisal study time. The program consists of 2 weeks of instruction in the classrcom, 3 weeks of simulator operation and one week of NRC-type written and operational examinations.
Trainees are instructed in the control room in groups of three, with every studeat operating the simulator at each of the three operating positions. Emphasis is on operational orientation with the trainee concentrating or learning the basic plant operations, casualty procedures, performing assigned evaluations and handling improved casualties. Lectures reviewing plant systems from an operational and functional viewpoint are used to supplement simulator operation. Plant operating procedures are presented as a planned sequence coinciding with actual operations on the simulator. _19/
1183 129 26
Replacement Operator Training / T303. The purpose of this program is to provide training for " hot" license candidates in plant operations by opera-tir7 the B&W simulator. The two-week course is evenly diviced between the classrooom (40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br />) and the simulator (40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br />). The method of instruc-tion is classroom discussion followed by practical demonstrations on the simulator.
Simulator exercises provide the student with experience in con-trolling normal and emergency plant evolutions with emphasis on operation of the Integrated Control System (ICS).
This course also includes an NRC-type startup examination on the simulator.20,/
Certification is made to the utility management that students have satisfactorily completed the startu9 examination.
The typical course schedule is as follows: --21/
Day 1 Day 7 Introduction Engineered safety features actuation Control panels system review Startup procedures Reactor coolent system leaks Reactor criticality Reactor coolant pump and/or feedwater pump trips Day 2 Day 8 Reactivity balance calculations Steam leaks, turbine by-pass valve and Plant shutdown (hot shutdown feedwater subsystem operation to 25 percent power)
Turbine by pass valve and feedwater Plant startup (hot shutdown subsystem failure to 25 percent power with turbine-generator in operation)
Day 3 Day 9 Technical specifications Control rod drive operation related to startup Control rod drive malfunction Power operations and and instrument failures major malfunctions Day 4 Day 10 Review of startup procedure Review and power operation with Reactor startup practice unannounced casualties Day 5 Startup examination Day 6 Integrated control systems (ICS) op,eration Manual / automatic ICS power operation including turbine and reactor trips 118;3 130 27
Simulator Requalification Training / T304. The Simulator Requalifi-cation Training Program provides assistance to the utility in meeting operator on-the-job requirements for an operator requalification program as specified by 10 CFR 55, Appendix A.
The program includes a review of recent abnormal occurrences applicable to program includes a review of recent abnor-mal occurrences applicable to B&W plant operations as well as a review of the utility's abnormal and emergency procedures. Instructions consists of 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> of practical exercixes on the B&W simulator and 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> of classroom instruction.
Day 1 Day 4 Introduction Review of procedures:
reactor trip, turbine trip, steam Review of procedures:
reactor rupture startup and ccatrol rod Review of selected transients and drive operation plant response Control room orientation Practical exercise: power Practical exercise: plant operations, manual integrated startup (from all rods control system operations, in to 20 percent power) instrumentation failures Day 2 Day 5 Review of procedures:
general Review plant response to selected power operations nonnuclear instrumentation Integrated control system review failures Control rod drive malfunctions Review of safety analysis and Review of operating curves and reactor protective system set points limits Practical exercise: power operations, Practical exercise: plant manual integrated control system startup (1 percent shutdown to operations, instrumentation 100 percent power), integrated failures control system operation in auto and manual, control-rod drive malfunctions Day 3 Review of technical specificaticns Evaluation of leak rates Practical exercise:
reactor coolant, system rupture, steam generator tube-leaks 1l83 131 28 9
Facilities and Equipment. The B&W Nuclear Training Center occupies approximately 4,000 square feet of space and includes two classrooms, two study rooms, a technical reference area, and a PWR simulator.23/
Each of the two classrooms is designed to accommodate 24 students.
The classrooms are equipped with self-contained audiovisual aid systems.
A student response system is utilized for rapid and continuous monitoring of comprehension of classroom presentations.
The PkR simulator is modeled after the Rancho Seco (SMUD) nuclear
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generating station control room.
It represents the B&W 177 fuel assembly, lowered loop nuclear steam supply. The consoles are essentially the same as those in control rooms of all B&W-designed nuclear power plants.
The main consoles of the simulator are electronically coupled to a digital computer which is programmed to simulate the dynamic performance of the actual plant. Movement of control devices by the student initiates responses from the computer which, in turn, sends back signals to the consoles for moving dials, energizing lights, and actuating alarms.
The following systems are included in the simulation:
reactor core control rod drives reactor coolant system steam generators steam, condensate, feedwater turbine generator let-down and make-up deboration chemical addition decay heat all emergency injection intermediate cooling raw water cooling radiation monitoring instrumentation protection and safeguards reactor building electrical automatic control In addition to the dynamics of these systems, the simulation includes
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all logic operations associated with mode change of valves, motors, and signals.
Additional realism can be created by duplicating and/or simulating the annunciator panels, communications, control room light fluctuations, and background noise.
The instructor's control room and console is located adjacent to the simulator control room. From this console,.the instructor can perform the following functions:
ready the plant for training operations at any one of 16 different conditions, including subcritical, critical, various 1183 132 29
power levels, various stages of core burnup, various poison levels, and various temperature and pressure levels; act as load dispatcher for the utility's power network which involves setting the electric load demand to the simulated plant; act as "outside plant assistant" in performing certain operations which are not designed for remote control at the main consoles, and; introduce any one of approximately 80 simulated plant malfunctions.
Most of these malfunctions are not simply "on-off" type, but rather can be the type that can only be controlled by proper operator action.
Actual duplicates of the integrated control system hardware are installed with the simulator and interfaced with other components.
A " freeze" feature is included whereby all computed variables are held constant and then released on separate commands from the instructor.
All console meters will hold while the instructor emphasizes or reviews some critical point in a transient.
EVALUATION OF OPERATOR, SELECTION, TRAINING, LICENSING AND STAFFING NRC Requirements and Implementing Procedures. As was discussed in the first part of this paper, the requirements for operator licensing are contained in 10 CFR 50 and 10 CFR 55.
There are no requirements for operator selection and training; guidelines are given in Regulatory Guide and ANSI Standard 18.1-1971. Further guidance for licensing is contained in the NRC Licensing Guide.
The aggregate of these regulations, guides, and standards form a body of procedures which by mutual conseat and common understanding institutionalize the training and licensing of nuclear reactor plant operators. The requirements which do exist are very limited in scope and in many respects are vague with regard to intent.
Part 50 of 10 CFR, which is concerned with facility licensing, makes few, general statements regarding the operators who will manipultte the reactor controls and their qualifications. Part 55 of 10 CFR, Operator Licenses, provides only a framework for the licensing process although it does include a more detailed description of requalification requirements in an appendix which was added in 1973.
Operator licensing regulations as a whole provide sufficient details as to the administration of operator licensing and qualification but they are deficient in defining the scope and depth of theoretical knowledge and practical factors necessary to ensure competent reactor operators.
The Licensing Guide,.which need not be complied with, expands on the provisions of the rd,ulations; this document, as well, does not provide adequate guidance. Significant deficiencies in regulatory requirements include the following:
1183 133 30
There are no requirements concerning the qualification of engineers and managers. These persons, who would likely be called upon in case of an accident to make significant decisions which could directly affect tne outcome, are not required to be licensed. Those who do hold SR0 licenses are not required to demonstrate a level of knowledge any more compreheraive than that of the reactor operators. Thus, a superior at 'ity to rationalize an unusual set of circumstances or to deat with a situation not predicted by procedure writers would be based solely on past educational achievements rather than a comprehensive knowledge of the reactor plant. The "last line of defense," the engineer, is perhaps less qualified than the persons who turn to him for direction.
The auxiliary operators, who operate apparatus and mechanisms that affect the reactivity or power level of the reactor, are not subject to any regulatory requirements concerning their qualifications or level of knowledge. The persons responsible for the operation of the condensate and feedwater systems of TMI-2, for example, were auxiliary operators.
The regulations do not address any aspects of the licensing process other than the written examination and an operating test.
Licensing examinations and tests, because of time constraints, can only be spot checks. There are no requirements in the regulations that trainees demonstrate a satisfactory level of theoretical knowledge in individual areas, as determined by qualified utility examiners, or that certain practical factors be performed. There are no prescribed areas in which a high level of theoretical knowledge must be attained.
Part 55.21 includes areas in which questions will be asked on written licensing examinations but the emphasis of these questions is on details of construction, operation, procedures, functions, and characteristics. Review of the content of operator written examinations and sample operator examination questions given in the Operator Licensing Guide, as well as questions which have been given in actual operator examinations, confirm that the regulatory philosophy is to concentrate on the "whats", "how manys", and " lists" and not the " whys."
For instance, 28 of the sample questions in the Licensing Guide begin with the word "what" and only two begin with "why".
As far as content of the written examinations is concerned, there are no questions asked of reactor operators about the principles of decay heat production and removal, the importance of keeping the core covered, core cooling, thermodynamic principles, the principles of saturation, subcooling and superheat, radiation theory, or reactor kinetics.
In summary, the regulations promote a shallow level of operator knowledge.
Operator Eligibility and Selection. The Nuclear Regulatory Commissioa has no requirements concerning minimum education, experience, reliability, criminal record or stress fitness. It merely endorses a guideline standard established by the American National Standards Iustitute in 1971 and does not require adherence to it.
A follow-on standard dated 1978 has not been endorsed although the NRC Operator Licensing Branch, B&W Training Department, and Three Mile Island Training Department are " kind of going by it." 24/
1183 134 31
As far as the guidelines are concerned, operators and senior reactor operators of nuclear power plants, which have the potential for great impact on the public health and safety, need only be high school graduates or equivalent. The term " equivalent" is nowhere defined.
In fact, there are no firm educational guidelines. The chief of the NRC Operator Licensing Branch has stated that no one has ever been refused a license because of a lack of education. It is considered that if a candidate can make it through a utility training program he must not have any substantial educational deficiencies. 25/
The guidelines recommend that an operator or senior operator license candidate have a minimum of one year of nuclear power plant experience.
The term " power plant experience" is nowhere defined. Power plant experience can be gained prior to the time that a plant is operated at power such as during the startup program. 26/ The OLB also gives credit for nuclear experience which a candidate may have gained in the Navy regardless of his length of service, his type of duty, his rating (electrical, mechanical, reactor) or his performance. 27/ In cold licensing, experience credit is given for all off-site training. 28/
A license applicant must submit a certificate of medical examination attesting to his physical condition. 29/ It also includes a brief medical history prepared by the applicant. The applicant must indicate whether or not he has ever been treated for a mental or nervous condition and whether he has ever been rejected for or discharged from employment because of mental or nervous disorder. Medical examination for the NRC license application does not provide for any psychiatric screening nor is there any consideration given to the candidate's ability to respond in stressful situations.
Similarly, there is no investigation of an applicant's criminal history other than requiring him to indicate in his medical history statements whether he has ever been convicted of a law violation resulting in a fine of $25 or more. The Operator Licensing Branch does not verify any of the responses given in medical history certificates. 30/
Training. Again, the Nuclear Regulatory Commission has no training requirements for either utilities or NSSS vendors who provide simulator services; provisions in ANSI 18.1-1971 concerning the training of licensed and nonlicensed operators as well as general employee training are only recommendations. There are no minimum training requirements.
NRC is involved in operator raining programs to a limited degree.
Specific actions taken are as follows:
The initial training programs at Three Mile Island were developed by Met Ed and submitted to the NRC for a paper review and approval. Some advice was given by the NRC in setting up the cold licensing training program. 31/ The hot license (Category IV) training program and replacement operator training programs were given paper reviewr, by the OLB as they were developed. There have been no further reviews and the OLB has not conducted any audits of the Met Ed training program, other than requalification.32/
1183 135
I The Met Ed requalification program is given spotcheck audits periodically by the Office of Inspection and Enforcement. This inspection, which is ostensibly for the purpose of verifying that the requalification training program is conducted in accordance with regulatory requirements,33/ is essentially a review of records.
Inspectors neither monitor the conduct of lectures nor offer comments on the substance of material covered. 34/
The OLB was " heavily involved in the initial setup of the Babcock & Wilcox cold licensing program" in the early 1970s. This involved examining the first graduates and becoming satisfied that the program "would do the job."35/ A paper review of B&W course T301 (New Plant Operator Training) was performed without comment in 1976.
36/
About every 6 months an OLB repretentative has observed the conduct of a startup certification test at B&W.
He has not provided a written report of his observations.
Other than these actions the NRC is not significantly involved in the training of operators. Specifically, neitber OLB nor I&E has any criteria for or involvement in the following areas:
staffing or qualifications of instructors in the Met Ed and B&W training departments except that senior simulator instructors should have held SRO licenses at sometime in the past (this is an unwritten requirement);
qualifications of the head of either training department; in-depth audits of training conducted at either Three Mile Island or Babcock & Wilcox; content or conduct of simulator training programs for either replacement operators or requalification (in fact, simulator training is not even required by the NRC); 38/
and content or conduct of classroom training at either IMI or B&W, with exception of verifying that scheduled requalification lectures were held at TMI.
The OLB does not have any objection to utilities " teaching the test."
In fact " mock" NRC examinations are encouraged and most utilities give them.
Giving such " mock" exams reportedly lightens the workload of the OLB. 39/
With regard to training its own people in reactor operations, the Operator Licensing Branch occasionally has sent members to B&W for special simulator courses. The last time that this-was done was in 1973 or 1974. 40/ Although a course was being set up for I&E inspectors at B&W, as of the time of the TMI-2 accident none had attended such a Course.
}r*
7/
J3
\\
According to the chief of the Operator Licensing Branch, the NRC has not reviewed either training programs or instructor qualifications but rather goes by the end product, that is, the licensing examination results. 41/
Operator Examinations and Tests. Reactor operator and senior reactor operator candidates must pass written examinations administered by the h3C in order to receive their licenses. The written examinations for reactor operators cover the seven categories required by 10 CFR 50 and require approximately 6 to 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> to complete.
Senior reactor operator candidates must be examined on five additional categories which include reactor theory, radioactive material handling, specific operating characteristics, fuel handling, and administrative procedures. The SRO examination requires an additional 4 to 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />. Reactor operator and senior reactor operator examinations differ principally in that the senior categories are more difficult and delve into plant operation more deeply. The difference between these examinations appears to be ill-defined. Additionally, the examinations reflect the defects of the regulatory requirements which have been discussed above.
In addition to the written examination, candidates must pass an operating test which also requires about 4 to 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> to complete. The operating test consists of three parts: a theoretical oral examination, a talk-through of normal and abnormal operations in the control room, and, finally, a walk-through of the plant. Oral examinations for SR0 candidates are optional. No such examination has been given at Three Mile Island.
Examiners are responsible not only for administering the examination and operating test, but also for preparation and evaluation of the results. As of the time of the accident at Three Mile Island the Operator Licensing Branch consisted of only eight examiners, seven of whom were degreed engineers and three of whom had been licensed at one time. 42/
These examiners are organized into three groups 4_3/ to facilitate the Branch's work.
Eight persons cannot effectively handle the licensing examination task for the entire United States. Therefore, the OLB has resorted to hiring consultants to work on a part-time basis to prepare, give and evaluate operator license examinations and operating tests. At the presznt the OLB has in its employ.2 part-time examiners; about half work full-time for national laboratories M/ or the Hanford Reservation Site and about half are college professors. Few of the consultant examiners have had any experience with commercial reactors. M/
Examinations are prepared by the persons who will administer them.
Questions are taken from a " bank" of about 400 questions from previous examinations or from the plant's FSAR, radiation protection manual, emergency plan, licensee event reports (LERs), and so on.
Examinations prepared by OLB members are not reviewed for content but rather they are passed around to ensure they are "givable".
Examinations prepared by consultants are reviewed by an OLB group leader at least 2 weeks before the examination is to be given. There is no record kept of this review.
-46/
1183 1,37 34
I Examinations are administered at the plant site to a group of candidates. The examinations are graded in Washington or the consultant's home office. Thus, results are not available at the time the oral examination is given to permit probing weak areas in depth.
The passing grade for the NRC written license examination is 70 percent overall. A person can fail one or more categories of the examination and still pass overall. Additionally, a person who fails one or more categories but scores greater than 70 percent overall need not receive additional training in the unsatisfactory areas. 47/
Review of statistics for the years 1975 to 1978 indicates that of 852 reactor operator examinations given, 88 percent of the applicants passed. Of 377 previously licensed applicants taking the SRO examination, 90.2 percent passed. Of 560 first time SR0 applicants, that is, those not previously licensed as reactor operators, 88.8 percent passed. 48/
Three Mile Island candidates have fared better than average. Since 1974 at the reactor operator level there have been no failures of about 30 candidates for " hot" licenses. The failure rate of 55 persons seeking senior reactor operator licenses was 12 percent.
Significantly, the failure rate of " upgrade SR0s"- persons already holding reactor operator licenses--was zero. All those who were unsuccessful were " instant SR0s." 49/
In testimony before the Subcommittee on Energy and the Environment of the House Interior and Insular Affairs Committee on May 24, 1979, the het Ed vice president for Generation stated:
At the recent American Nuclear Society Symposium on Training at Gatlinburg, Tennessee April 29 - May 2, 1979, J. Holman of the NRC issued statistics on NRC license failure rates.
In the period of 1971-1974 the failure rate in the industry was 15.2 percent. For this same period, TMI failure rate was 12.1 percent. For the period of 1975-1978, the industry failure rate was 11.5 percent.
For this same period, the TMI failure rate was 5.3 percent.
"ois would indicate that the effectiveness of the Met Ed training program was better than the industry average.
License Issuance. The chief of the NRC, Operator Licensing Branch is the grantor of all reactor operator and senior reactor operator licenses. His decisions are not subject to any review except for denials which must be approved by his superior, the assistant director of the Division of Project Management for Quality Assurance and Operations.
The chief of OLB uses a medical consultant to review each license application but it is he who grants all waivers and conditional licenses.
Typical conditions include requiring the operator to wear eyeglasses, to receive more frequent medical examinations than normal, or to operate the reactor only with another operator present. 50/ Licenses are issued for a 2 year period but, unless an operator is unable to complete the requirements of the utility-administered requalification program, it is unlikely that he will ever again interact directly with the NRC. Under very unusual circumstances the operators license could be revoked. Of fl b lb 35
the approximately 2,500 operators in the country, the. LRC has suspended one operator license and required reexaminations of only six other operators. 51/
Requalification. Licenses for both reactor operators and senior reactor operators are of 2 years duration. A license will be renewed by the NRC without examination provided that the operator's physical condition is good and:
He has actively and extensively engaged as an operator, has discharged his duties competently and safely and is capable of esntinuing to do so.
He has completed a requalification program.
The requalification program is conducted by the utility and should be audited by I&E representatives for its quality. The NRC requires through 10 CFR 55 that a written evaluation examination be given.
In addition, there is an informal requirement that an oral examination of each licensee also be conducted. The NPC has declared informally that if anyone gets less than 80 percent in a category of the written examination that person should go to a lecture on the subject.
If a person gets less than 70 percent in the annual written exam or is unsatisfactory in his oral examination, he must go into accelerated training.
If he is unsatisfactory in both written and oral exams, he may not perform duties associated with reactor control.
If an operator fails the written exam, he may or may not continue as an operator depending on the utility's program. 52/
The requalification program must also require each operator to manipulate the controls at least 10 times in a 2-year period. Such manipulation may be performed on a simulator.
OLB reviews the results of the annual evaluation examination.
During the administration of writte i operator examinations, the examiner spotchecks annual written evaluation examinations given by the utility.
Normally about six examinations are selected for spotchecl s of examination adequacy and fairness of grading. Most recently at Three Mile Island, three R0 and three SR0 examinations were chosen representing high, medium, and low grades with about 3 to 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> being spent in the review.
No written evaluation was given by the OLB examiner at the conclusion of the review. 53/ No further evaluation of the requalification program written examination is performed by the NRC.
The Inspection and Enforcement Division performs spot checks to verify that the utility is carrying out its requalification program.
This is a paperwork review which occurs at least once per year and is performed in the case of Three Mile Island by inspectors from the NRC Region I Office, King of Prussia, Pennsylvania. The persons who inspect training and qualification records specialize in that area. 54/ Written reports are submitted to the utility.
1183 139 36
Summary. The NRC's involvement in the administration of operator training is quite limited. Requirements in 10 CFR 50 and 10 CFR 55 are not comprehensive and guidelines in ANSI standards are very limited in scope. The Operator Licensing Branch is quite limited in resources and is heavily overloaded. The OLB has not received the support which it has needed to carry out an effective job. f.J/ Too much reliance is placed on part-time examiners who lack the proper qualifications for licensing operators. There are no internal audits of the OLB to evaluate its effectiveness. The net effect is that NRC does not ensure a comprehensive level of knowledge of those persons who operate reactors or supervise their operation.
Babcock &Wilcox Training Services Staffing and Organization. Although the utility is responsible for training its own operators it is impractical, if not impossible, for operators to receive the required operational and emergency training on the control panel of the generating facility. The cost of outages which would result from such training would be prohibitive. A simulator which accurately reproduces the operating characteristics of the facility involved and in which the arrangement of the instrumentation and controls of the simulator quite closely parallels that of the facility involved permits operators to receive the requisite training in an acceptable manner. Inasmuch as such simulators are quite expensive, most utilities do not possess them, but, rather, utilize the simulator training provided by another organization.
The Babceck & Wilcox Company operates a simulator, described earlier, for its customers. A series of courses built up around this simulator have also been discussed. Simulator training services which the B&W Company provides to customers are exactly that. The B&W Training Papartment is a service organization which does what the customers ask for. 56/
That B&W simulator training represents in terms of time only a small portion of the whole training program for reactor operators has been emphasized by B&W representatives. An operator could spend as little as 2 weeks every two years at Lynchburg. 57/ However, the emergency craining which is covered in that short interval is of great importance to safe reactor plant operation, mitigation of the effects M casualties, and ultimately protecting g public. To state that "the uu Mty is responsible for training" -
is, perhaps, an oversimplification. The Babcock & Wilcox Company bears a great deal of responsibility for operator training.
To accomplish this task, the Training Services Section of the Customer Services Department is comprised of a manager, five senior instructors, two associate instructors, and other individuals responsible for simulator programming, seminar coordination, videotaping, and plant operation. The manager, an engineer, has been with the company for over seven years. None of the instructors is a degreed engineer, although all senior instructors were formerly licensed as senior reactor operators.
Instructors are not res ired to periodically requalify as operators. 59/
u 8
40 37
It is not clear how the Training Services Section is organized.
The lead instructor stated that the Manager of Training Services is not responsible to any degree for the formulation of the training program.
Rather, the lead instructor said he was responsible for training specifics. M/
The manager stated that since taking over that position in 1972 he had instituted many changes to make the section more customer-oriented and to staff the organization with experienced operators rather than engineers who lacked experience. The changes were based on consultations with the customer utilities in 1972-1974. 6_1/
Management / Engineering Role in Training. The Training Services Section has essentially functioned independently of Nuclear Power Generating Division management, the NPGD Engineering Department, and Met Ed management.
The head of the former Customer Services Department, of which Training Services was a part until February 1979, stated that he never reviewed the content of the training program and that no such reviews were made from outside the Training Services Section.
62/ Regular meetings were not held between engineering and training personnel. J / In fact, there was a general lack of interaction and information flow between engineering and training. There was no formal mechanism to integrate design and training. 6,4/ One senior engineer was not sure if there was a training section. 65/
That engineering and design personnel had no little influence on training is not surprising, for engineers had almost no first-hand knowledge of nuclear reactor operations. 65_/ Neither the head of the Engineering Department, a B&W engineer for over 20 years, nor the head of licensing, a B&W engineer for 25 years, had ever observed a B&W-designed nuclear steam supply system in operation at power. 66/ Nearly all engineers asked made similar responses. The head of the Design Section stated that he did not know if engineers from design had received training from Training Services. The head of the Engineering Department did not know if any engineer had ever observed courses given to the customers. He further estimated that less than 20 percent of B&W engineers had received simulator training. 67/ The vice president, NPGD, indicated that he had devoted little attention to training. 68/
In a similar fashion Met Ed management had not observed training conducted by Babcock & Wilcox for TMI operators. I.ower-level management personnel from Met Ed had attended courses at B&W as a part of their own qualification or requalification but no one had come to Lynchburg for the express purpose of evaluating the effectiveness of classroom and simulator training. 6,9/
Training Contract. The mechanism by which training services are to be provided are defined in a contract drawn up between the Babcock &
Wilcox Company and a purchaser which is generally a utility.
In the case of Met Ed, a long-term training service contract was agreed upon in March 1975 and was to be effective until December 31, 1979. This contract originally provided for three segments of training as follows:
1.
a base scope for annual operator requalification and
}4j replacement training; 38
2.
prescheduled, committed simulator instruction as may be mutually agreed; and 3.
other programs as may be mutually agreed.
Annual attachments to the contract provide rates for the base scope of effort as well as rates for prescheduled simulator training.
The contract was amended in August 1976 to redefine the base scope of effort and to specify the number of sin.ulator hours and classroom hours which would be provided through 1979. A number of change orders have been issued to the original and amended contracts to include courses not covered by the base scope of effort. For example, in 1977 seven change orders were executed to cover cold license courses, startup ce Mification courses, refresher training, chemistry courses, and videotapes and instruction manuals, all in addition to the base scope of effort.
70/
Training Services is separately accounted for in the NPGD. On the basis of direct costs, this section has not lost money. 71/
Course Administration. 'ihe three principal training courses as far as Met Ed has been concerned are cold licensing (New Plant Operator T301), hot licensing (Replacement Operator T303), and requalification (Simulator Requalification T304). These courses consist of both classroom and simulator instruction.
Review of records associated with classroom instruction in these three courses and intervien of Training Services personnel identified a number of deficiencies or non-optimal techniques which detract from the effectiveness of instruction.
Included in these are the following:
There is no indication that actual plant operating experiences are effectively incorporated in the classroom. For instance, the Davis-Besse transient of September 24,1977, was alleged to have been mentioned to some students from an unidentified utility,72/ but there is no record of this nor is there an indication in Met Ed training records that such events from actual operations have been covered.
There are no syllabi for these courses.
Course content is determined when the weekly schedule is prepared. 73/
There are no training manuals used to standardize the material covered in the ccurses offered to TMI Unit 2 operators and to assist in teaching.
Documents such as the FSAR and Technical Specifications are used, but these are not texts. A training manual was produced and used for TMI-1 operators. A similar manual was not produced for TIM-2 operator training because it was not in the contract. M/
In the cold license and hot license courses, emphasis is given to,eaching students to pass the NRC examination rather than concentrating on fundamentals.
Students are given old NRC examinations to study. H/
M84i42 39
Weekly and final examinations are given in the cold license course.
In neither the hot license course nor the requalification courses are quizzes given to test the effectiveness of classroom instruction. 76/
Homework is not assigned to students because bargaining units would rcquire the payment of overtime. However, the Training Services manager believes that homework is not necessary because B&W provides training and not education. 77/
Lectures are not monitored and instructors are not monitored for effectiveness. Lecture evaluation sheets are prepared for and sent to the Three Mile Island Training Department. These evaluations are signed by a B&W instructor and are generally devoid of any comments. 78/
No audits of training methods and efiectiveness are performed by anyone outside Training Services. Nobody in B&W management above the Training Services section has given attention to course administration. 79/ There is little evidence that there has been a consciousness of the need for course upgrading at B&W.
Simulator Training. The B&W Training Center simulator, which is the so-called "SMUD" design, 80/.!equately represents the controls and indication for TMI-2. 81/ Prior te the accident on March 28, 1979, this was not true because the simulator was unable to simulate the formation of steam voids in the reactor coolant system. That is, it was not possible to simulate an increasing pressurizer level at the same time reactor coolant inventory was dimini.shing. This problem has been corrected since March 28, 1979, and the simulator can now represent a transient of the nature of that experienced at TMI-2.
However, the simulator still lacks any indication of PORV position, either direct or indirect.
Although simulator training is considered by the operators to be valuable, the B&W simulator has not been employed adequately in light of the TMI-2 accident. Specifically:
The evolutions and drills have been simple and repeated course after course. Compare, for example, the major drills covered in two simulator courses nearly 6 years apart:
June 1, 1973 March 23, 1979 Dropped Rod - 1 Dropped Rod - 2 Stuck Rod - 1 Stuck Rod - 1 Reactor Trip - 2 Reactor Trip - 2 RCS Leak - 2 RCS Leak - 1 Turbine Trip - 3 Turbine Trip - 2 OTSG lube Failure - 1 Steam Leak - 2 Steam Leak - 3 Although the number of drills and evolutions conducted j ] g"}
}4 during a given period in the simulator has increased in recent years, the additional evolutions and drills have 40
been minor in nature, involving, for example instrumentation failures, valve malfunctions, or pump failures.
As many as 10 to 15 casualties have been run in an hour. All would ' e single failure rather than multiple failure drills.
o Casualties were carried only through the immediate action steps rather than to their logical conclusion. For instance, a loss-of-coolant accident might not be carried pas; the point of ECCS actuation or getting a high pressure in the reactor building. 82/ ECCS actuation was not simulated with subsequent failures.
Casur':ies in the simulator were not dealt with by a crew; B&W discouraged more than three persons in the simulator at a time, although more than this could be accommodated. There was no person who stood back and was in overall charge. All three trainees were involved in manipulations. The functions of extra reactor operators, the shif t supervisor, or an engineer, were not simulated. 83/
Operators functioned based on their knowledge of procedures rather than breaking out and referring to the procedures themselves. This was, perhaps, due to the fact that the B&W Training Services section did not have a set of TMI-2 operating and emergency procedures. 84/ Procedures for use in the simulator were available but they were significantly different from those in use in the TMI-2 control room.
Procedures, which are required to be followed for a small-break loss-of-coolant accident (LOCA) and which were developed in response to an early 1978 B&W accident analysis, were not used in the B&W simulator. These procedures req'.. ire, among other things, for one reactor operator to be designated as a small break LOCA operator and for this person to perform certain actions at prescribed times. The Manager, Training, Services was not aware that such assignments and actions were required.
85/
B&W Training Services has developed no drill guides or equivalent which would accomplish the following:
assign a specific objective for each drill; provide a general description of the drill; indicate the method of initiation, including the symptoms to be provided to the trainees; provide a sequence of expected action; specify the point of termination to ensure the objectives were achievable; or permit management review and approval of the scope of training conducted.
41 1183 144
Trainees' performance on the simulator is not evaluated in the requalification program; in the replacement operator program only the reactor startup is evaluated. This is particularly significant in the case of requalification because the simulator is normally the only practical casualty training that a reactor operator receives during the requalification cycle. There is no mechanism for reporting to the utility that a licensed operator did not perform satisfactorily in simulated reactor emergencies. 86/
Met Ed management has not observed the performance of TMI-2 operators ir the simulator for the purpose of evaluating operator proficiency. 87_/
One of the requirements of 10 CFR 55 is that each licensed operator perform at least 10 reactivity manipulations each 2 years. These manipulations may be performed on a simulator ft t the purpose of meeting requalification requirements. At the B&W simulator all trainees present in the simulator have been given credit for a reactivity manipulation whether they operated the controls or not.88/ The NRC OLB chief was unaware of this practice and disapproEd of it.
89/
The importance of keeping the core covered was not emphasized in the simulator.
Natural circulation was not practiced to the point of cold shutdown.
Training Related to the Loss-of Coolant Accident. The core of the TMI-2 reactor was damaged because operators failed to respond correctly to the symptoms of a loss of coolant through a stuck-open pilot-operated relief valve (PORV). A complicating factor was pressurizer level increasing, rather than decreasing, at the same time that reactor coolant system pressure dropped.
The operators did not recognize the symptoms of a loss-of-coolant accident and they were incorrectly concerned about reducing the pressurizer level at a time when water should have been added rather than removed from the plant.
Inasmuch as the Babcock & Wilcox Company was the foremost authority concerning response of the B&W-designed plant to accidents and because it had a significant role in the training TMI-2 operators to correctly react to accident symptoms, it is important that the training given to these operators with respect to a small-break loss-of-coolant accident be evaluated. The issues which relate to that training are:
whether the B&W NPGD was aware that the plant would respond as it did on March 28, 1979; whether the manner in which the B&W plant would be expected to respond to a small-break LOCA from the pressurizer steam space was included in operator training and how operators were taught to respond; what B&W taught in simulator courses concerning permitting the pressurizer to go solid; 1183 145 42
what was taught simulator students about saturation conditions in the reactor coolant system; and whether operators were taught to keep the reactor core covered with water.
On September 24, 1977, Toledo Edison's Davis-3 esse 1 plant, which is similar to TMI-2, experienced a transient very similar to that which occurred in the March 28, 1979, event. The PORV for the pressurizer stuck open,-causing rapid depressurization and actuation of the HPI system. Unexpectedly, a short time after the onset of the transier.t, pressurizer level began to rise. Relying on that indication alone, the operator terminated HPI. The transient continued for about 21 minutes until the operators shut the PORV block #alve, terminating the loss of coolant and stopping reactor coolant system depressurization.
The detsils of what occurred at Babcock & Wilcox are covered in another section of the report. Aspects of those events which pertain to operator training will be mentioned briefly here.
An engineer from the B&W Plant Integration Unit was sent to Davis Besse on September 25, 1977, to review the transient. Upon his return, he briefed about 30 employees of his findings. On November 1, 1977, because of his concern whether operators of B&W plants had been properly instructed about interrupting HPI following such an event, he wrote a memorandum 9_0/ in which he stated:
Since there are accidents which require the continuous operation of the high pressure injection system, I wonder what guidance, if any, we should be giving to our customers on when they can safely shut the system down following an accident
.?
I would appreciate your thoughts on this subject.
The only written response which he received was a memorandum 91/
dated November 10, 1977, from a supervisory engineer in Nuclear Service who pointed out:
In talking with training personnel and in the opinion of this writer, the operators at Toledo responded in the correct manner considering how they had been trained and the reasons behind this training.
\\My assumption and the training assumes first that RC (Reactor 9 oolant) Pressure and Pressurizer Level will trend in the same direction under a LOCA (loss of coolant accident). For a small leak, they keep the HP System up to a certain flow to maintain Presr.
(Pressurizer) on Level.
He also stated that an instruction calling for continued operation of HPI might caise questions of vessel mechanics and of the RCS " going solid."
When no action had been taken on the matter, the manager of the Emergency Core Cooling System (ECCS) Unit wrote a memorandum 92/ dated February 9,1978, to the manager of licensing in which he stated:
43 1183 146
The direct concern here rose out of the recent incident at Toledo (Davis-Besse). During the accident the operator terminated high pressure injection due to an apparent system recovery indicated by high level within the pressurizer.
This action would have been acceptable only after the primary system had been in a subcooled state. Analysis of the data from the transient currently indicates that the system was in a two phase (steam and water) state and as such did not contain sufficient capacity to allow high pressure injection termination. This became evident at some 20 to 30 minutes following termination of injection when the pressurizer level again collapsed and injection had to be reinitiated. During the 20 to 30 minutes following termination of injection when the pressurizer level again collapsed and 30 minutes of noninjection flow, they were continuously losing important fluid inventory even though the pressurizer indicated high level.
I believe it fortunate that Toledo was at an extremely low power and extremely low burnup. Had this event occurred in a reactor at full power with other than insignificant burnup, it is possible, perhaps probable, that core uncovery and possible fuel damage would have resulted.
The incident points out that we have not supplied information to reactor operators in the area of recovery from LOCA.
(emphasis supplied)
I believe this is a very serious matter and deserves our prompt attention and correction.
Action to inform reactor operators was not taken until April 4,1979, a week after the TMI-2 accident. The guidance which was given to operators of B&W-designed power plants was essentially that contained in the February 9, 1978, memorandum. Authors of both the November 1, 1977, memorandem and the February 9, 1978, memorandum agreed that if the operators had done what was contained in their memoranda there would have been no accident. at Three Mile Island. 93/
Aside from failing to inform the customers that HPI should not be interrupted during a loss-of-coolant accident, action was not taken within the B&W training organization to apprise operators of the details of the Davis-Besse transient or to discuss the implications of premature stopping of HPI. The manager of Training Service was at Davis-Besse on the day following the transient and w informed of the transient but did not understand its implications. gj He was subsequently provided a copy of the November 1, 1977, memorandum but cannot remember receiving a copy and took no action as a result. The Davis-Besse transient was not modeled in the simulator and the lessons learned were not incorporated into the training program although an instructor may have discussed the transient with trainees from at least one utility. 96/
Engineers occasionally discuss loss-of-coolant accidents in a 2-hour lecture on safety analysis to students undergoing requalification training. This was last done for Met Ed students on January 23, 1978.
44 1183 147
The lecture has been given for the past 3 or 4 years, but not by the ECCS unit; rather it has been given by another unit of the Design Section, the Safety Analysis Unit, whose responsibilities did not include LOCAs.
97/ Similarly, LOCAs were not specifically covered in lectures given by Training Services instructors. 98/
Considerable confusion exists about the issue of whether the pressurizer should be allowed to go solid, even among the key members of the Engineering Department. For example, the Plant Design Section engineer who investigated the Davis-Besse transient believes there is nothing wrong with going solid in the plant. 99/ The supervisory engineer in Plant Performance Services who wrote the November 18, 1977, memorandum believes that operators are taught not to go solid at any time. 100/ The manager of the ECCS Unit believes there is nothing written, " good or bad," about taking the plant solid. 101/ The manager of the Plant Performance Services Section expressed concern in a memorandum dated August 3,1978, about allowing the reactor coolant system to go solid. 102/
As far as training of operators at B&W is concerned, the manager of Training Services stated that trainees are not told not to go solid; in fact, they have not been taught anything specific about pressurizer level. 103/ He was also not familiar with the B&W Engineering Department philosophy on going solid. Training Services had not covered in the simulator the phenomenon of pressurizer level increasing at the same time reactor coolant system pressure was decreasing. 104/ The Operations Manual for the B&W nuclear power plant simulator does not make any reference to pressurizer level while in the hot standby condition. 105/
There are, however, requirements in various documents which clearly define what pressurizer levels should be maintained by the operators:
Babcock & Wilcox Limits and Precautions 106/ for pressurizer operations state:
The pressurizer must not be filled with water to indicated solid water conditions (400 inches) at any time, except as required for system < hydrostatic tests.
The pressurizer Limiting Condition for Operation in the o
Operating License Technical Specification, 107/ states:
3.4.4 The pressurizer shall be OPERABLE with:
a.
A steam bubble b.
A water volume between 240 and 1330 cublic feet (45 and 385 inches)
APPLICABILITY: Modes 1, 2 and 3.
TMI-2 Operating Procedure OP 2103-1.3 Revision 3, 7/19/78, Pressurizer Operation, states:
2.1.8 The pressurizer /RC System must not be filled with coolant to solid conditions (400 inches) at anytime except as required for system hydrostatic tests.
45 1183 148'
2.2.7 While in modes 1,2 and 3, the pressurizer shall be OPERABLE with:
a.
Steam bubble, and b.
a water volume between 240 and 1330 cubic feet (45 and 385 inches) (TS-3.4-4).
Neither the Limits and Precautions, Technical Specifications for pressurizer operation, nor the TMI-2 operating procedure were used in the training program at B&W. 103/
Interviews and depositions of Training Services staff members as well as examination of training records indicate that the principle of keeping the core covered with water was not specifically treated in the training program. Additionally, the concept of saturation and translation of pressure-temperature relationships to saturation conditions were not emphasized. There was no steam table available for operator use in the simulator control room. 109/
Courses Taken by TMI Personnel. Records of training conducted by Babcock & Wilcox for Met Ed operators since May 1973 were examined.
Tabs A - H summarize these courses including type, length, dates, attendees, material covered, and results. Of particular interest is that drills involving a stuck-open PORV or loss of main and emergency feedwater were not covered in these 6 years.
1183 149 46
TABS A.
Two-week Simulator Course B.
Simulator Preparation Course C.
One-week Special Simulator Course D.
Eight-week Cold License Certification E.
One-week Cold License Refresher F.
Special Five-week Cold License Certification G.
Replacement Operator Training /Startup Certification H.
Requalification Note:
Those persons whose names are underlined are licensed either as a reactor operator or senior reactor operator on TMI-2.
1183 150 47
TAB A Two-week Simulator Course 1.
Completion Date Attendees May 18, 1973 HerbeinSI, Porter,, Smith June 1, 1973 Floyd2I,Hydrick,Conrad June 15, 1973 Colitz, Chwastyk, Miller June 29, 1973 Gilbert, Potts, Smith Beers, Desh, Ross !
1 July 13, 1973 July 27, 1973 Kunder1I,Wallace,Fredland 1I August 17, 1973 Guthrie, Noll, Evans, Book August 31, 1973 Derks, BoltzSI,Hitz,Mehler September 28, 1973 0'Hanlon, Baer, Hartman /
2 N
November 16, 1973 Bryan, Wynn, Heilman, Perks Goodlavage, Keisch, Morgan, Reich November 30, 1973 Banks, Acher, Zewe, Pilstz December 14, 1973 Bulmer, Keyser, Harper, Cotter Brown !, Crouse, tty, Summers, S
June 1, 1974 Williams, Zechman S!, Landers,SeelingerSI February 14, 1975 Orlandi 2.
Curriculum Hours Sir.alator 40 Lecture 26 Study 10 Written Exam 4
1183 151
-48
3.
Major Drills (Average number per person)
.94 Turbine Trip 1.1 Steam Rupture 0.7 Dropped Rod 0.6 Stuck Rod 0.1 Dropped Rod 0.6 Stuck Rod 0.1 RCS Leak 0.7 4.
None of the 54 course attendees failed.
5.
Evaluations of the students were prepared. All lacked substantive comments.
6.
Notes 1/
Now a member of B&W Training Services 2/
Currently in TMI Training Department 3/
Engineer / Manager 4/
Former B&W Instructor 5/
Persons whose names are underlined currently hold licenses on Unit 2 It83 152 49
a TAB B Simulator Preparation Course 1.
Dates April 23-26, 1973 17 Attendees July 30 - 3 August, 1973 20 Attendees 2.
This special simulator preparation course which was of 4 days' duration included lectures on fluids and electrical systems, components, plant startup and shutdcwn procedures, and some ab. normal operations. A quiz was given at the concittsion of the course.
1183 153 50 t
TAB C One-week Special Simulator Course 1.
Comp 1'< ion Date Attendees October 18, 1974 Crouse,Banley,BrownE!
February 3, 1978 Bezilla, Fuhrer February 10, 1978 Wearn, Fels February 17, 1978 Mackey, Crawford 2.
Curriculum Hours Simulator 20 Classroom 20 3.
Major Drills (Average number per person)
.67 Turbine Trip
.22 Steam Rupture
.44 Dropped Rod
.67 Stuck Rod
.22 RCS Leak
.44 4.
Notes 1/
Students prepared critiques 2/
Currently in TMI Training Department 1183 154 51
TAB D Eight-week " Cold" License Certification 1.
Inclusive Dates Attendees January 10 - March 4,1978 Thompson 1I, Hartman /, Faust, 2
Coleman, Congdon 2.
Curriculum Hours Simulator 100 Classroom 180 Lectures / exams 141 Self-study 39 3.
Major Drills (Average number per person)
Reactor Trip 2.0 Stuck Rod
.20 Dropped Rod 1.4 RCS Leak 1.6 OTSG Tube Rupture
.40 Steam Lean 2.6 Turbine Trip
.40 4.
Weekly and final examinations were given in each of the seven categories of the NRC written exam.
In addition, startup, oral, and operating exams were given, all with satisfactory results.
5 Notes:
1/
Due to lack of experience Thompson's oral was given at TMI 6/1/77 2/
Employment terminated 4/79 1183 155 52
TAB E One-week Cold License Reference Course 1.
Completion Date Attendees June 10, 1977 Beers 1/ Frederick A. Miller, Congdon, 7
Adams, Seelingert 2
June 17, 1977 Ross, Hutchinson, Coleman, West, Desh, Hitz 2/
June 24, 1977 Floyd
, Neumann, Hartman, Smith, Bocher, Hoyt July 1, 1977 Zewe, Marshall 2/, Wright, Mehler, Scheimann, Faust July 8, 1977 Chwastyk, Illjes, Thompson, Guthrie, Tydon, Conaway 2.
Curriculum Hours Control Rod Drive 2
Diamond Panel Review 2
ICS Review 4
RPS 2
Safety Analysis 2
OTSG Review 2
Reactivity Changes 2
Review 2
Simulator 20 3.
Major Drills (Average number per person)
.83 Turbine Trip
.47 RCS Leak
.43 Dropped Rod
.57 1i(13 156 53
Stuck Rod 17 OTSG Tube Failure
.60 Steam Leak
.83 4.
There were no examinations, grades, or student evaluations in"this Course.
5.
Notes 1]
Now in TMI Training Department 2_/
Engineer / Manager O
e
\\ \\85 D1 54
TAB F Five-week Cold License Certification Course (Special) 1.
Inclusive Dates January 16 - February 17, 1978 2.
Attendee J. Logan, Prospective Superintendent, Unit 2.
3.
Classroom Hours Systems 36 Theory / Physics / Safety 16 Procedures 48 Exams 16 Tour 2
Review 6
Total 124 4.
Simulator Hours Planned Evaluation / Drills 66 Unannounced Drills 12 5.
Major Drills Hours Dropped Rod 6
Stuck Rod 2
RCS Leak 6
Steam Leak 4
OTSG Tube Rupture 1
PORV Stuck Open 0
Loss of Feed 0
6.
Evaluation of Written Exams Week one -
Elementary level of knowledge required concerning plant materials air systems Week two -
Ten questions of the " list," "what is," " sketch,"
" describe" categories Week three -
Ten short answer questions concerning operational questions Week four -
Ten short answers on operational and emergency procedures required; short answers to a specific problem or failure 1183 158 33
Final examination - Fifteen short-answer questions (10 cf the questions were repeats of questions asked in the weekly study)
The documentation package includes 41 lesson / course attendance sheets and 41 lesson evaluation sheets. These are both Met Ed forms inasmuch as B&W has no requirement to keep attendance records or to evaluate lessons. The evaluations of instruction were all completed by H. Heilmer, a B&W instructor who himself presented 20 of 41 lessons.
The evaluation sheets contain only brief statements of the material covered in the lessons and do not include any evaluation of the material covered, trainees performance, or instructor effectiveness, as they are required to do.
O e
a 56
TAB G T303-Replacement Operator Training /Startup Certification 1.
Inclusive Dates Attendees 1I, Tydon, Parnell May 23 - June 1977 Marshall October 31 - November 4, 1977 Wilkerson, Bailey October 31 - November 11, 1977 Masters November 7-11, 1977 Shipman 1I, Goodman March 20-31, 1978 Kidwell, Eusted, Smith, Woodell May 15-19, 1978 Cooper, Olson June 26 - July 7, 1978 Weaver, Bozer, Pearce October 2-13, 1978 McGovern, Logan 1I, Hermmila October 16-27, 1978 Zechman /, Shipman 1I, Hartman !, Brantley 2
1 February 12-23, 1979 Kendig, Smith, Herman, Mayhue February 26 - March 9, 1979 Phillipe, Garrison, Germer, Brumner, Mell 2.
Curriculum (hours)
First Week Second Week Introduction (1)
Integrated Control System (2)
Control Rod Drive System (4)
Reactor Trip / Turbine Trip (2)
Nuclear Instrument /RPS (2)
ESF/RCS Leaks (2)
Reactor Physics (2)
RCP/MFP Trips (2)
Reactivity Balance (4)
Steam Leaks (2)
ECP Problems / Study (2)
Feed System Failures (2)
ECP Calculations (2)
CRD Malfunctions (2)
Gral Certification Exam /
Instrument Failures (2)
Study (2)
Review (4) 3.
Major Drills / Evaluations (Average number per person)
Week One Week Two Reactor Trip
.6 1.6 Turbine Trip
.3
.7 RCS Leak
.3
.5 Steam Leak
.5
.8 OTSG Tube Failure
.16
.15 Dropped Rod
.5
.5 Stuck Rod 0
.2 Reactor Startups 6.9 5.6 118.5 i60
4.
Evaluation All but two (Shipman, Goodman) of the 33 persons who took this course were administered a startup certification examination in accordance with Appendix F of the NRC Operator Licensing Guide.
Copies of startup certification letters were sent to the chief of the Operator Licensing Branch, NRC. Review of the startup examination results indicate that none of the 31 persons being examined received an unsatisfactory evaluation in any category. Comments which were recorded are of little value in ascertaining operator performance.
5.
Critique sheets were submitted by the students. They lack substantive comments and are replete with praise for thc instructors.
6.
Notes 1/
Manager / Engineer 2/
Supervisor of TMI Training Department e=
58
TAB H T304-Requalification (One Week) 1.
Completion Date Attendees Ross1h,ParnelgBoyer,Chalecki, January 13, 1978 Floyd-Brown, Bryan January 20, 1978 Acher,Deg,Heilman, James, Seelinger, b. Smith, D. Smith January 27, 1978 Crouse, Mehler, Kunde d, Deiter, Masters, Pilsitz, Zewe January 6, 1979 Acher, Heilman, Hartman !,
1 January 12, 1979 Bryan,Parnell,Sgth,Guthrie, Goodlavage, Brown
, Geruer January 19, 1979 Zewe, Branti Mayhue,Rossg, Masters,Pilsitz, January 26, 1979 Chwastyk, Banks, Ruppert, Crouse, Hutchinson, Deitec, Flanagan February 5, 1979 Noll, foyer,Keisch,Kandig,Mehler, Beers
, Husted February 9, 1979 James,Chalegi,Woodell,Hitz, Smith, Boltz, Fraser March 16, 1979 Congdon, Adams, Cooper. Mehler, Orwig March 23, 1979 A. Miller, Wright, Olson, Coleman, Hitz, Marshall, Kunder March 28, 1979 (Partial)
Floyd1!
, Smith March 30, 1979 Hartman, Bocher, Hoyt, Blessing 2.
Classroom Curriculum Hours Push Pull 0-2 Control Rod Dri-- Review 4
Integrated Control System 4-6 Heat Transfer 0-2 (Seldom included)
Power Distribution 0-2 Heatup/Cooldown 0-2 Safety Analysis 0-2 (Seldom included)
OTSG Review 0-2 TOTAL 20-22 1183 162
3.
Major Drills (Average number per person)
.55 Dropped Rod
.60 Stuck Rod
.32 RCS Leak
.55 Steam Leak
.96 OTSG Tube Failure
.40 PORV Stuck Open 0
Total Loss of Feedwater 0
B e
9 60
i Three Mile Island Training at Three Mile Island for reactor operators, senior reactor operators, and auxiliary operators was significantly deficient. The training of operators did not prepare them to cope with the accident which occurred on March 28, 1979. Review of the events which took place indicate the persons in the control room should have teen able to recognize symptoms which indicated the core was being hazarded and should have eliminated these hazards. However, that which was, taught them did not ensure that they understood what was happening. Shortcomings in the organization, management, staffing, and curriculum as well as erroneous or incorrect training on specific issues related to the accident are discussed below.
TMI Training Department Staffing and Organization.
The staff of the Training Department, as it existed on March 28, 1979, consisted of a supervisor of training, two technical training groups and an administrative assistant. The technical training groups, one for licensed operator training and the other for non-licensed operator training, were each headed by a group supervisor. The licensed operator trait *eg group included two instructors and the non-licensed group, one instructor.
This organization is shown in Figure 1.
The supervisor of the licensed operator technical training group is responsible for reactor operator and senior reactor operator initial training, administration of licensing requirements, and senior reactor operator upgrade training. The non-licensed training group is involved in auxiliary operator training, health physics training, and ANSI requirements training for general employees.
The supervisor of training has been employed by Met Ed since 1969 when he was hired to organize a Training Department and a training prcgram for TMI-1 operators. He does not have a degree and has been working unsuccessfully on a reactor operator license for more than 5 years.
In September 1978 he became a full-time trainee for an operator license although he was not relieved of duties as supervisor of training.
He was not able to closely oversee the training program because of his own qualification effort. 110/ The supervisor of training was less knowledgeable of training program particulars than members of his staff.
For instance, he did not know, when asked, whether separate annual requalification written examinations are given to TMI-1 and TMI-2 operators.
He was not familiar with the significant change in loss-of-coolant accident procedures which were instituted in May 1978. He was not aware of the procedure for examining license candidates with no reactor startup demonstration as described in Appendix F to the NRC Operater Licensing Guide; this is the procedure used by Met Ed for licensing replacement operators. He was not familiar with details of the annual oral examination procedure. 111/
The group supervisor of Technical Training for Licensed Operators has been at Three Mile Island for about 9 years. He is a qualified senior reactor operator on both Unit I and Unit 2 and has extensive experience as a shift supervisor. He does not have a baccalaureate degree. The licensed operator group supervisor is knowledgeable of and involved in all aspects of operator licensing and training.
I183 164 6
There are two instructors who train licensed operators. They both have extensive experience at TMI and both are qualified as senior reactor operators on Unit 1.
Both are high school graduates.
The group supervisor of Non-Licensed Operator Training does not hold either a reactor operator or senior reactor operator license.
His single instructor is licensed as a reactor operator on Unit 1.
Working conditions for members of the Training Department have not been good. The many changes in the head of the training department have had adverse effects due to the lack of continuity. At times the position has been vacant. At least five changes have taken place in as many years. 112/ The Training Department has been undermanned and the' workload has been heavy. The group supervisor for training licensed operators says he has been overloaded since his first day in the Training Department.
113/ There has been a high turnover rate of operators since TMI-1 went commercial, which increased the magnitude of the training task; there have been as many as 20 persons in the Category IV (replacement operator) program. IM/ Another adversity has been that instructors are reportedly burdened by administrative requirements. 115/
The lack of sufficient numbers of qualified persons probably has degraded the effectiveness of the Training Department.
1183 165 62
Figure 1: TMI Training Organizatior.
Met Ed Manager of Quality Assurance (Readia.g)
Supervisor of Training - TMI Group Supervisor Administrative Group Supervisor Non-Licensed Operator Assistant Licensed Operator Technical Training Technical Instructor Instructor Instructor C
A B
1183 166 53
Management and Training. Management's la a of 'nvolvement has also had a deleterious impact on the ability of the Training Department to
' function effectively. Neither the unit manager nor the station manager considered that he was responsible for the training of reactor operators nor had they been responsible for or involved in the content of the training program. IM / The Training Department was considered only to provide a service to use. 117/
At the time of the TMI-2 accident the Training Department did not, in fact, report to anyone on the Island. The supervisor of training was directly responsible to Met Ed's manager of quality assurance in Reading, Pennsylvania.
In addition to being responsible for training of operators and quality assurance throughout the Met Ed system, the manager of quality assurance was also in charge of quality control and security.
He stated that he visited Three Mile Island only about once per month and was able to devote little attention to training.ll8/
Training responsibility was moved to Reading during construction because of the inability to manage it at Three Mile Island. ly/
Responsibility was reassigned to the superintendent of TMI-1 in May 1979, but on June 26, 1979, neither the station manager nor the superintenddnt ofTMI-?wereawareofthis.))/
No in-depth audit of the functioning of the Training Departmen), no review of the adequacy of scope or depth of instruction given to operators nor monitoring the effectiveness of simulator training at Babcock &
Wilcox had been performed by Met-Ed managers prior to the accident on March 28, 1979.
2ialuation of Training Programs. Training performed by the Training Department, as has been described above, consists of general employee training, auxiliary operator training, the replacement operator (Category IV) program and requalification of 1. censed operators. General employee training takes place on an irregular as-needed basis. Auxiliary o;.erator
'C' training is conducted on a full-time basis for 9 weeks before the operator carries out any duties in the plant. Auxiliary operators 'B' also spend 6 weeks, full-time, in the classroom taking part in a formal curriculum.
Training for auxitiary operators on shif t is conducted in the same fashion as for licensed reactor operators and senior reactor operators; one week per shift cycle is spent in training.
Prior to January 1, 1979, there were five shifts, so operators spent one week out of five in training. Subsequently, the addition of shift
'F' meant that one week out of six was spent in the Training Department. The tra ning week consists of the 0700-1500 shift Monday to Friday.
Considerable reliance is placed on chift foremen and,'to lesser extent, on shift supervisors to train the persons in their shifts.
But supervisors and foremen are a mually heavily involved in administrative duties during routine shifts and are unable to devote attention to operator training. Estimates of the amount of time required for taking care of paperwork on shif t vary between 60 to 75 percent. 12_1/
1 In addition to using solely Training Department assets, some use is made of consulting firms. For instance, the NUS Company of Rockville, Md., will perform nearly any training service needed.
1_22/ The Training 2
Department has an NUS package which includes a modular program with video tapes.
1183 167 c.
General Employee Training. Training of general employees as recommended by ANSI 18.1-1971 is scheduled by department heads. This program will not be further evaluated here.
Auxiliary Operator Training. Auxiliary operator training is not defined formally in an administrative precedure.
It is described informally in a training memorandum which was not approved by management. P-view of the auxiliary operator 'C' training program indicates that the operators received adequate formal instruction to permit them to commence on-shif t training. The material covered and the administration of the 9-week classroom program gives the 'C' A0s sufficient knowledge nf systems and equipmeat. There is lacking, however, instruction of an iategrative nature which would help them understand how the. systems and equipment support the reactor. Additionally, it appears that auxiliary operators
'C' do not receive sufficient supervision to enable them to apply what they learned in the classroom to practice.
Auxiliary operator training outside the A0
'c' and A0 'B' classroom courses is ill-defined and sporadic. The goals of auxiliary operator training a-2 not clear, particularly for A0 ' A's.
Further, the training which has eeen performed has not enhanced their understanding of responsiblities with respect to reactor safety. Such responsibility is significant, as was emphasized by the events initiating the accident on March 23, 1979.
Examination of records for auxiliary operator training, other than the classroom sessions for A0 'C's and A0 'B's, indicates that between May 8,1978, when formal training began for TMI-2 operators, and March 28, 1978, auxiliary operators went through 10 training weeks.
Formal training during this time included:
Topics Industrial Waste Systems Portable. Survey Equipment NET Program Fire Fighting General Employee Training - Emergency Procedure Security Review Evaporator Training Caution Tags Quality Assurance First Aid Radiological Emergency Drill Communications Administrative Procedures Work Request Procedures Water and Waste Treatment Condensate Polishers Snubber Inspection Of the 400 hours0.00463 days <br />0.111 hours <br />6.613757e-4 weeks <br />1.522e-4 months <br /> spent in the Training Department during these weeks, a total of 119 hours0.00138 days <br />0.0331 hours <br />1.967593e-4 weeks <br />4.52795e-5 months <br /> were devoted to formal training. During most of each week the training schedule indicated that auxiliary operators were not engaged in training. What they_did during the approximate 70 percent of the time when they were not :in formal training is not known.
} l h, b
Review of the topics covered shows that auxiliary operators received no training concerning reactor operation, reactor safety, radiological controls, radiation theory, chemistry, electrical safety, reactor theory, and so on. Such topics would be appropriate for operators who can directly affect reactor safety, who are exposed to radiation and who are involved with radioactive material. The auxiliary operator training program requires significant upgrading to take advantage of the 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> which are available during each training week and to give emphasis to knowledge needed to ensure safe reactor operation and minimize radiation exposure to the auxiliary operators.
Replacement Operator Training (Category IV Program).
The Category IV Program, which over a 9-month period prepares candidates for reactor operator license examinations, is described by a Training Department administrative memorandum 123/ not approved formally by the Supervisor of Operations or any of his superiors. The program is completed essentially on a self-study basis. However, the Training Department does provide study assignment sheets which outline the trainees' required effort; reading assignment and physical tracing are listed for various systems and equipments. In addition, a questionnaire is provided for each syster-covered.
The program is fundamentally one of familiarization with the design, construction, operation, and interrelationships of systems and equipment in the plant.
Included is coverage of administrative, operations, and emergency procedures. There is little emphasis given to theory, application of theoretical to the practical, or, principles of either the operating or casualty procedures. Nothing is included in the course study assignents in the areas of reactor theory, primary plant thermodynamics, or secondary the rmodynamics. There are no requirements for the study of such concepts as saturatica, enthalpy, decay heat production, or solid system operation.
Virtually no knowledge of chemistry is required. Rather, the emphasis is on systems, equipment, and procedures; topics included are listed in Table 1.
Trainees may come off shift to attend lectures on specific topics such as reactor theory, integrated control system reviews, health physics review, or refueling reviews. Examination of weekly training schedules does not indicate that this is done in practice.
Review of questions included in the system questionnaires and in the examinations given to test the trainees' knowledge indicates that they are expected to memorize but not necessarily gain a comprehensive understanding of the material covered in the course curriculum. Questions are nearly all of the "what is," " list," "how many," " draw a one-line diagram of" type. There are few questions which begin with "why."
Trainees are expected to spend only about 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> per day on training.
Checkouts to determine their level of ksvalpige are performed by the shif t supervisor, shif t foreman, or a ' %:ns:d training coordinator.
Checkouts are r at performed by perr.y >, a mi;ht be expected to have a superior educa.ional background
.. h w ne supervisor of operations or to evaluate Category IV trainees' unit superintendent. There is c.
.u
.s real depth of knowledge.
As a part of the replacement operation for goalification program the trainees demonstrate their ability to conduct a teactor startup, change reactor power, and respond correctly to normal and emergency 66 1183 169
procedures at the B&W simulator. The TMI Training Department has little do with the B&W Startup Certification. 124/ Met Ed managers do not eterve the performances of trainees at Lynchburg. 125/
At the conclusion of the Category IV program a " mock" NRC examination is given before the NRC Operator Licensing Branch examiner comes to the site. Ideally, the mock exam would be given about 2 to 4 weeks before the actual NRC exam but this period could be as long as 5 months. 126/
The Met Ed replacement operator program is well administered. In addition, the program's success rate has been perfect. Of 43 persons applying to the NRC for reactor operator licenses since 1974 there have been no failures. 127/ Nevertheless, the Category IV program does not ensure that reactor operators gain a broad understanding of the theoretical base for plant design or a comprehensive knowledge of the principles of the operating and emergency procedures.
1183 170 67
Table 1 Topics Covered in Category IV Training Programs Cycle 1-1 Administrative Procedures Circulating Water Systems River Water Systems Cycle 1-2 Feedwater Systems Condensate Systems Main and Reheat Steam Systems Extraction Steam / Heat Drains Turbine Generator - Mechanical Cycle 2-1 Make-up and Purification Systems Decay Heat Removal Systems Chemistry Cycle 2-2 SFAS Core Flood Systems Reactor Building Spray Systems Cycle 3-1 Turbine Generator Control Systems Cycle 3-2 Reactor Protection Systems Non-nuclear Instrumentation Nuclear Instrument Systems Reactor Coolant Systems Reactor Coolant Pumps Cycle 5-1 Health Physics Radiation Monitoring Systems Cycle 5-2 Reactivity Balance Heat Balance Cycle 6-1 Review:
Administrative Procedures Operating Procedures Emergency Procedures83 )[} Technical Specifications Reactor Theory 68
Senior Reactor Operator Training. Persons presently licensed as senior reactor operators at TMI-2 have gained this qualificaiton either through " cross licensing" or by means of the SRO " upgrade" program. Cross licensing is a process by which persons who were qualified on Unit 1 obtained a license on Unit 2 without having to take an NRC license examination on Unit 2. SR0's with Unit I licenses were administered a 10-week course in June-August 1978, which covered the differences in the design and procedure between Units I and 2. 128/ The NRC accepted documentation from the TMI Training Department that the candidates had participated in the differences program and had passed written examinations on these differences. The NRC reviewed the content of the differences examination. No oral examinations were given. The SRO upgrade program is the method by which persons who are qualified as CR0s prepare for NRC SRO license examination. This program too is not formally described in an administrative procedure. It is a total self-study effort, one month in length. The Training Department does provide study outlines and some guidance but this is essentially a self-help program. Success of candidates for SR0 licenses has not been as good as for CR0 licenses. Of 59 applicants for SR0 licenses since 1974, 50 were successful. Requalification. Met-Ed's program for requalification of reactor operators and senior reactor operators is formally described and approved in Administrative Procedure (AP) 1006, previously described. Many deficiencies were noted in the content and administration of this program. Operational Review Lecture Series (OR). The requalification program's principal means for ensuring operator knowledge on a continuing basis is the Operational Review Lecture Series (OR). According to the requirements of AP 1006 the OR series will include the following topics as a minimum each year: Reportable Occurrences Unit Modifications Operating History and Problems Procedure Changes Abnormal and Emergency Procedure Review Technical Specifications Major Operational Evaluations Applicable Portions of 10 CFR FSR Program Material, that is, topics directly related to the different areas of the NRC licensing examination. OR series lectures are required to consist of at least 60 scheduled hours per requalification cycle or about 1.2 hours per week. 1183 172
Since the beginning of the requalification program in May 1978 operators were in five shifts until January 1, 1979. Subsequently, they were in six shifts. The shift rotation is organized so that operators have one training shift per cycle. Thus, an operator would be expected to have a training week consisting of 40 hours, Monday to Friday, each 5 or 6 weeks. Review of records indicates that both the amount of time devoted to training each training week as well as the material covered were deficient. In the 46 weeks between May 8, 1978, and March 28, 1979, the typical reactor operator or senior reactor operator was in training for nearly 10 weeks. During the 10 cycles betseen those dates (400 hours) the typical trainee received 214 hours of formal instruction. Whereas this exceeded the 60 hour minimum prescribed by AP 1006 it represented only about 53 percent of the time in which the operator was "in training." The remainder of the time was devoted to " Operator in the Plant" or nothing. " Operator in the Plant" is ostensibly for the purpose of practical requalification vork in the plant. In practice, however, it amounts to operators spending a shif t in the plant just watching. Some of the time supposedly devoted to lectures is misleading. For instance, the training schedule indicates a 6-hour period for emergency procedures. In actuality, 5 hours were for self-study on shift and one hour was for a one-hour test on emergency procedures. This test, which was given over a period of 5 weeks, was the only quiz given in the OR Series; that is, no quizzes were given to determine the effectiveness of lectures. The shift supervisor of the March 28 shift (11:00 a.m. to 7:00 p.m.) failed this emergency procedure test which consisted of questions beginning as follows: " List," "How often," "What action," "What," " List," " List," " List," " List," " List," " List," "What," " List," "How much," and "How long;" there was not a single "Why." The material which was covered did not fulfill requirements of either AP 1006 or 10 CFR 55, Appendix A. Referring to the topics covered in the OR series after May 3, 1978, as listed in Table 2, no lecture was given which covered the details of reportable occurrences, their causes, and corrective action; operating history and experience in such a fashion as to cover significant lessons learned in other plants; in-depth discussion of procedure changes such as the modification to Emergency Procedure 2101-1.3, Reactor Coolant System Leak to incorporate small-break LOCA action; emergency procedure review (except for those procedures required to be covered under Health Physics Procedure 1670); or Fundamentals and System Review Program material. As can be seen from Table 2 most of the lectures given were of little value in promoting safe reactor operation. The lectures which were related to reactor operation might be considered the following: HOURS } }83 }f 3 Standardized Technical Specification Review 4 Integrated Control System 6 Reactor Theory 10 70
Nuclear Instruments 2 10 CFR 2 Operating History / Experiences 1 Reactor Protection System Review 1 Reportable Occurrences 2 Emergency Procedures Review 2 Reactivity Balance 4 Features of Facility Design 2 General and Specific Operating Characteristics 2 Instrumentation and Controls 2' Safety and Emergency Systems 2 Decay Heat Removal System 8 50 Thus, only slightly more than an hour per week was devoted to instruction related to reactor operation. Twelve hours of instruction on fire fighting, 129/ 4 hours on security, 8 hours of first-aid training, 8 hours on fuel handling, and 32 hours of health physics / radiological emergency training were undoubtedly important. However, the lack of emphasis given to theoretical instruction concerning such material as decay heat, core cooling, thermodynamics, saturation. principles of operating procedures, and principles of emergency procedures was significant. The operators were not taught in such a fashion as to prepare them to cope with a situation not covered precisely in the emergency procedures. Only one hour was devoted to " Operating History / Experiences." This lecture was the method by which operators would be exposed to transients and other phenomena experienced in other plants; its intent was to relate lessons learned to obviate repetition. Review of the lesson plan for this lecture indicates that the entire session was devoted to a discussion of relatively minor material problems such as with reactor coolant pump snubbers, reactor building doors and diesel engines. No personnel-related occurrences or events were discussed. In preparing for this lecture the instructor reviewed the Licensee Event Report (LER) Summary dated December 9, 1977, which included the transient at Davis-Besse on September 24, 1977. The summary of that transient was vague and misleading in that it made no reference to the significant issues of the event. ^130/ The instructor did not understand the transient's significanceT 131/ 1183 174 71
Table 2: Reactor Operator / Senior Reactor Operator Formal Requalification Training, May 8, 1978 - March 28, 1979 May 8 - June 9, 1978 Hours Cross License Exam Review 2 Standardized Technical Specification Review 2 Integrated Control System (ICS) Review 2 Technical Specification Review 2 Operations /ICS Review 4 Emergency Procedure Review Techniques 1 Requalification Exam Review _3 16 June 12 - July 14, 1978 Hours Fire Fighting 8 General Employee Training-Emergency Procedures 2 Security Review 2 General Employee Training - Health Physics _4 k \\ 0. 16 72
July 17 - August 18, 1978 yours Reactor Theory 8 Nuclear Instruments 2 10 CFR 2 Operating History / Experiences 1 Caution Tags 1 Operational Quality Assurances 2 Fire System Technical Specifications 4 Radiological Emergency Drill 4 24
- Same day Note: D Shift got add'tional fire fighting training in lieu of reactor theory.
August 21 - September 22, 1978 Hours First Aid 8 ~ Emergency Producures HPP 1670 Radiological Emergency Drill Training _8 16 1183 176 73
September 24 - October 27, 1978 Hours ISI Review 2 Station Communications / Radiological Emergency Training 2 Emergency Procedures HPP 1670 2 Reactor Protection System Review I Radiation Monitor System Review _8 8
- Same day October 30 - November 19, 1978 Hours Health Physics Recertification 4
Fuel Handling 6 Underwater Video 2 Loose Parts Monitor 2 Reportable Occurrences 2 Math Review 2 Radiation Monitor System 2 Emergency Procedures Review 2 Reactivity Balance 4 26
- Same day 118.5 177 74
i November 20 - December 2, 1978 Hours Nothing December 4-11, 1978 Hours Health Physics Review 4 December 11 -\\ 22, 1978 Hours Health Physics Recertification 4 Reactor Theory 4 Radiation Control 2 Fuel Handling 2 Features of Facility Design
- 2 General and Specific Operating Characteristics
- 2 Instrumentation and Controls
- 2 Safety and Emergency Systems 2
20
- Same day
+ Same day December 25-29, 1978 Hours Nothing 1183 17B 75
January 1 - February 9, 1979 Hours Circulating Water / River Water Systems 8 Administrative Procedures 1 Work Request Procedure 1 Security System Modifications 2 NET Program 4 Water and Waste Treatment 4 Industrial Waste Treatment _8 28 February 12 - March 19, 1979 Fours Decay Heat Removal System 8 Condensate Polisher 4 Turbine _8 20 March 19-28, 1979 At Simulator Frequently, lectures were concentrated into 1 or 2 days a week as is indicated in Table 2. It is doubtful that coveriag such diverse topics as nuclear instruments,10 CFR, operating history / experiences, caution tags and. quality assurance all in one session promoted effective learning. Another significant deficiency in the requalification program was absenteeism from the OR Series. Attendance at these lectures averaged less than 50 percent a 4 was worse when the crew was on five shifts. 132/ Appendix Z which consists of three memoranda submitted by the licensed-operator group supervisor indicates that the attendance rate 76 1183 179
for senior reactor operators was significantly lower than for control room operators. The memorandum, dated February 16, 1979, also shows that the TMI-2 superintendent, TMI-1 superintendent, TMI-1 supervisor of operations, TMI-2 supervisor of operations, and TMI-2 operations engineer, all of whom were licensed operators, had attended no training in 1979. Those persons who are absent from lectures are given " care packages" by the Training Department. These are makeup requirements which consist usually of study assignments related to the material covered in lectures which were missed. Persons who are absent are required to complete a form indicating they have made up the material and to return the form to the Training Department. 133/ Low levels of attendance result in adding to the instructors' administrative burden. The OR series, as well as other training conducted, is listed in a weekly training schedule prepared by the liceused-operator group supervisor of training. There is ao specific cuarterly, semi annual or annual plan on which the weekly schedules are based. The Training Department honors requests from management concerning particular training needs; otherwise there is no input or review by managers. Copies of weekly training schedules are submitted to unit superintendents and several managers at the company's Reading headquarters. Lectures are neither evaluated for the purpose of upgrading nor are they monitored by managers as a method of ensuring high quality. 134/ On-the-Job Training (0JT). An important part of the requalification program is on-the-job training. The intent of this is to ensure that operators participate in a minimum number of reactivity manipulations and take part in surveillance testing, equipment checkout and equipment operation. There is a requirement that reactivity manipulations be diverse, that is, that many different types of evaluations be covered. The administr:4tive mechanism by which on-the-job training is recorded is the "0JT Book" maintained in the control room. Operators are expected to enter their own evaluations and reactivity manipulations in the book. Appropriate supervisors are required by AP 1006 to review the participation of licensed personnel in the OJT program. In fact, this task is performed by members of the Training Department. 135/ Staff review of the OJT Book indicates adequate numbers of reactivity manipulations with proper diversity were covered. Shif t supervisors at.J shif t foremen who are assigned the responsibility for overseeing on-the-job training devote most of their attention not to monitoring reactor operation or training subordinates but to taking care of administrative requirements. SR0s who are experienced as shift supervisors or shift foremen estimate that a foreman must spend from 50 to 80 percent of a shif t on paperwork. Supervisors try to tour each unit each shift but this is not always possible. 136/ Administrative requirements which restrict supervisory persons from overseeing training and observing the performance of plant opecators are listed in Table 3. 1183 180 77
Table 3: Shift Foreman Administrative Requirement 1. Radiological Work Procedures 2. Work Requests 3. Key Log 4. Lifted Lead / Jumpers Log 5. Temporary Change Log 6. Special Operations Foreman 7. Batch Process Log 8. Transient Cycle Log 9. Callout Work Sheets (Overtime) 10. Vacation Book 11. Absentee Book 12. Reportable Occurrences 13. Document Review Surveillance 14. Out of Service Stickers (Including Weekly Audit) 15. Do Not Operate / Caution Tag Log (Including Weekly Audit) 16. Switching and Tagging Book 78 1183 181
17. Fire System Removal From Service Log 18. Liquid Transfer Checklist Log 19. Individual Daily Time Report 20. Surveillance Reports 21. Secondary Logs 22. Out Building Logs 23. Control Room Logs (35-40 pages) 24. Shift Foreman Log 25. Operations Surveillance 26. Revision Review Book i1$3182 79
Annual Evaluation Examination. A key part of the requalification program is the annual written evaluation examination which is required to ensure that CRos and SR0s are maintaining an adequate level of knowleu Although it is not required, Met Ed also requires an oral evaluation examination conducted in conjunction with the written test. Both of these examinations simulate the original licensing examination and the operating test conducted by NRC examiners. The written annual evaluation examinations were in the format of NRC examinations; that is, the questions were arranged in categories A through G and H through L except that some categories were combined because of similarity. For example Category A on the requalification examination includes questions for NRC Category A (Principles of Reactor Operations) and Category H (Reactor Theory). Review of the questions asked indicates that the scope and depth of knowledge were approximately equivalent to those asked in NRC examination.137/ Of particular interest was one question concerning the conditions which would warrant small-break LOCA response. This will be further discussed below. According to the requirements of AP 1006, if a person receives less than 80 percent on any section of the examination he will attend the Fundamentals and System Review (FSR) Program related to the failed sections. If a licenseholder scores below 80 percent on two or more sections of the annual written examination, he will be given an oral examination and be evaluated for an accelerated training program (relieved of all duties) or permitted to continue his duties and participate in an FSR program. Review of the results for the licensed operators who took the examination in February 1979 indicates that two persons received overall grades of less than 80 percent. One of these persons, a TMI-2 CR0 received a score of less than 80 percent in four sections and scored less than 70 percent in one section. This operator was dismissed a few days after the March 28 accident. The other person who failed overall was the TMI-2 supervisor of operations, who scored less than 80 percent in five of the eight sections, less than 70 percent in three of eight sections and whose highest grade on any section was 83.9. This supervisor of operations had not as of June 27 been given an oral examination, as required, nor had he participated in remedial work. Among TMI-2 CR0s there were three operators who received grades of less than 80 percent on Section D (Instrumentation and Control) and three who scored less than 80 on Section C (General Operating Characteristics). Annual oral examinations were administered to all licensed operators between January and March 1979. The purpose ot the examinations was to determine an operator's knowledge of normal and emergency procedures, equipment operation, technical specifications, and emergency plans. The same checklist 138/ which specified systems and casualties to be discussed was used for all examinations. Review of completed checklists indicates that almost no individual item was unsatisfactory and nearly a complete absence of critical comments. No one failed the oral examination. ))Ob 0 80
Specific Training Deficiencies Related To The Accident. It is evident from a review of the events which took place on March 28 that operator error may have been a significant factor in the interpretation of information available and in the action which was taken or not taken in response to such interpretation. Such errors may have included the following: pressurizer level versus RCS pressure recognition of LOCA recognition of plant at saturation recognition of need to remove heat or how recognition of significance of radiation levals or high temperatures / pressures in reactor building The purpose of this section is to evaluate these responses or the failure to recognize conditions which existed in terms of the training which the operators had received at TMI. Pressurizer Level Versus Reactor Coolant Syst2m Pressure Interviews of operators and members of the Training Department yielded many statements to the effect that limits and precautions, operating procedures, and technical specifications forbid permitting the pressurizer level to go to indicated solid conditions while the plant is in hot standby. Instructors stated that they had taught operators not to allow the pressurizer to go dry and not to 1" it go solid because of the hazards of overpressurization. 139/ The pressurizer should not be allowed to go solid because of B&W limits and precautions. 140/ Reactor Coolant System Technical Specification 3.4.4 prohibits a pressurizer level of greater than 385 inches in Mode 3 even though nothing would probably be broken. 141/ If the plant goes solid, the pressure could exceed 2,900 psig; if code safety valves did not lift at pressure of greater than 2,750 psig, again a Technical Specification Limit, could be reached. 142/ All of these concerns are certainly valid in the non-emergency situation. What is not clear is what was actually taught to operators. Nothing was included in reviews of the emergency procedure for loss of coolant because the phenomenon of rising pressurizer level and decreasing system pressure had not been considered by the training staff. Pressurizer operation, which would include the limits and precautions of Operating Procedure 2103-1.3, was not covered in the requalification program. The matter of avoiding going solid was not covered at BFW simulator training. The Category IV training program (Cycle 4-1) did not include any discussion of pressurizer limits and precautions or hazards of going solid in other than Mode 1. No explicit training on not going solid in Mode 3 was referred to by the tdI Training Department. One deponent stated that not going solid had been stressed in training at TMI but he did not indicate h3w or when. 143/ The superintendent of TMI-1, who is licensed, an engineer, and when deposed responsible for training at Three Mile Island, perhaps most clearly described the situation when asked whether operators had been instructed to keep an inventory in the pressurizer and to keep the pressurizer from going solid 144/ 118'r 184
I would say yes, but I don't think the instruction in either case, particularly with respect to the solid, was brought out in as clear cut a way as I have just answered the question. I would say that I have expressed a philosophy in :nswering the question but I could not go back to statements in training notes and dig out that specific statement out (sic) of the training notes from either B&W or Metropolitan Edison. I have expressed a philosophy that one keeps inventory in the press-urizer, and I have expressed a philosophy that one does not take the pressurizer solid. The operators in interviews and depositions stated that the limits and precautions and technical specifications with respect to pressurizer level should not be violated. Nevertheless, it is evident that they also understood that although the existence of an emergency does not, ipso facto, give license to damage equipment, if tLe situation dictates, the operator may exceed the limits and precautions to move to a safer condition. 145/ This would suggest that the operators might not have recognized that an emergency existed when they lowered pressurizer level. Failure to Recognize a Loss-of-Coolant Accident There is evidence from the actions which were taken, as well as from statements made in depositions and interviews, that the operators did not realize a loss-of-coolant accident was in progress.146/ For some time in the early stages of the accident operators believed that because of the absence of radiation alarms in the reactor building a steam line break must have existed rather than a loss of coolant. 147/ This was in spite of the existence of the following symptoms listed in Emergency Procedure 2203-1.3 indicating that a luss-of-reactor-coolant accident was in progress: rapid centinuing decrease of reactor coelant pressure high reactor building sump level reactor building temperature alarms Increasing radiation levels, beginning 19 minutes after the turbine trip Review of training related to the loss-of-coolant situation provides some insights as to why the operators may not have recognized that a small-break LOCA existed. The Loss of Reactor Coolant / Reactor Coolant Pressure (Emergency Procedure 2202-1.3) was included in formal training only once during the year preceding the accident. 148/ The procedure was covered as a health physics rather than an operational requirement; Healt. Physics Procedure 1670.9 requires that EP 2202-1.3 be covered annually. The procedure was included in a 2-hour lecture along with four other emergency procedures. It is doubtful that the loss-of-coolant procedure was discussed in depth. More significant in evaluating whether the operators were predisposed to act in a certain way or, more accurately, to not act in response to symptoms of a small-break LOCA may be revealed in a discussion of the small-break LOCA procedure itself. 1183 185 82
On May 1, 1978, Babcock & Wilcox issued a document entitled " Analysis of Small Breaks in the Reactor Coolant Pump Discharge Piping for the B&W Lowered Loop 177 FA Plants," in which the worst-crse small-break was determined to be at the reactor coolant pump discharge. Results of the analysis show that it was necessary to use operator action during the early stages of the postulated small-break IOCA to effectively mitigate the accident consequences by achieving sufficient and balanced flow through all four HPI (high pressure injection) lines. Specifically, the B&W analysis suggested that the following actions be taken: o Upon ESFAS signal check for flow through both HPI trains. If no flow in one train: -- open pump header cross-connect valves; -- check HPI valve position and open if closed; -- secure flow through normal makeup line if flow is indicated; and -- throttle HPI valves as required to balance flow and run out limits. The analysis assumed, among other things, that no off-site power was available and that one complete train of high pressure injection failed. That is to say, even with these conditions the ccre would be protected if the prescribed operator action were taken. This analysis was evidently incorrectly interpreted by Met Ed. A letter from the vice president for generation to NRC dated May 5, 1978,149/ described the procedures change in response to the B&W analysis. Specifically, the letter stated: The control room LOCA operator will, within two (2) the event (small-break LOCA), analyze his indications and determine if there is a loss of offsite power cross connected with a diesel or make up pump failure and a small break LOCA. In the event of that occurrence. the Control Room LOCA operator will direct the make-up pump discharge cross connect valve opened and he will proceed to the EPI throttel valves in the auxiliary building and balance the flow between legs. Thus, the bounding conditions for the B&W analysis, that is, loss of off-site power and failure c' one HPI train, were interpreted by Met Ed to define when the action for a small break LOCA would be taken. In other words, such action would only be taken in case of the extremely unlikely concurrent loss of off-site power and loss of one HPI train due to pump failure or diesel failure. The letter further stated that, "Each shift will be rebriefed at least once per month of the action required in the procedures." On May 12, 1978, a change to EP 2202-1.3 was issued which added the following section:150/ 2.2.2 Small-Break LOCA Response } } 83 ) Ob 83
2.2.2.1 Within 2 minutes of the LOCA the CR0 dedicated to recognition of a small-break LOCA 151/ must complete the following: Verify that a small-break LOCA with single a. failure symptoms exists. Symptoms: 1. SFAS initiatica and only one make-up pump started, or 2. SFAS initiation and less of the 2-2E This indicates then that the interpretacion in the May 5,1978, letter to NRC was further misconstrued as a small-break LOCA because it was defined in terms of the loss of one HPI train or the loss of off-site power and the simultaneous loss of off-site power and one diesel, a most unlikely set of circumstances. This would possibly lead to the interpretation by operators that unless these circumstances were obtained there could not be a small-break LOCA. Interviews of operators determined just that interpretation. The operators in the control room during the accident thought that to have a small-break LOCA it was necessary to have a loss of off-site power, a loss of a diesel or loss of makeup pump, and a loss of coolant. 153/ Review of the annual written evaluation examination given to licensed operators in February 1979 indicates that the Training Department interpreted the situation in the same way as did the operators. Question F 3(a) was: " List the conditions as given in the emergency procedure, which would warrant small break LOCA response." The correct answer to this question was: "a) SFAS initiation 30d only one MUP started, or b) SFAS initiation and loss of 2-1E or 2-2E." It can be argued, therefore, that the operators failed to take action for a small-break LOCA on March 28 because the situation did not meet the criteria, as defined in their training, for a small-break LOCA. Another factor which may have influenced the operators' failure to realize the existence of a loss-of-coolant situation was that for 2.3 hours they did not recognize a stuck-open PORV. Their failure to do so has roots in the training which they had received. The emergency procedure review schedule subsequent to May 8, 1978 155/ indicates that Emergency Procedure 2202-1.5, Pressurizer System Failure, which gives in Section B the symptoms for and action to be taken if pilot-operated (electromatic) relief valve (RC-R2) fails open, was not included. One of the key symptoms of an open PORV is high temperatures (greater than 200* F) read on the discharge line. This temperature had been reading nearly 200* F before the accident because of relief or code safety valve seat leaks. During the time when the valve was stuck open, the operators repeatedly discounted discharge pipe temperature readings between 203* and 283' F because they believed that temneratures about the same as those of the pressurizer or RCS, 553 to 646 F, should have beet indicated for a stuck-open valve. In fact, isenthalpic expansion of pressurizer water through the stuck-open valve should have resulted i183 187 84
a in discharge pipe temperatures ranging between 219 and 302* F. 156/ A fundamental knowledge of thermodynamics was not included in either the Category IV or requalification program nor was it expected by the NRC. Most important, from the standpoint of training, of all the reascas for operators not recognizing the existence of a small-break LOCA was failure for the lessons learned in other transients such as at Oconee-1, October 13, 1975, and at Davis-Besse 1 on September 24, 1977, where PORVs stuck open, to be communicated to those persons who required that knowledge -- the operators. Serious concerns expressed by B&W engineers 8 and by an NRC inspector, who foresaw the significance of operator errors at Davis-Besse 1 and predicted serious consequences if the same error were repeated, were not made known to the utilities. As late as July 17, 1979, the group supervisor for licensed-operator training at TMI who was responsible for the content and conduct of such training had not heard of Dunn, Michelson, Cresswell, or Novak. Failure to Recognize That the Plant Was At Saturation In response to the high pressurizer level, operators throttled high pressure injection and increased let-down flow in a continuing attempt to reduce pressurizer level. This act resulted in reactor coolant system pressure dropping rapidly and almost steadily from normal operating pressure to about 1,000 psig. Pressure dropped slowly over the next 2 hours to about 600 psig. The operators interrreted this as a stable condition and were not concerned about the phenomenon. Relative stability of reactor coolant system pressure was the result, of course, of pressure decreasing to that corresponding to the bulk saturation temperature in the hettest part of the system. Difficulties with pressurizer heater operation and pressurizer temperatures equal to reactor coolant hot leg temperatures, which in turn were equal to surge line temperatures, did not indicate to the operators that the core was in jeopardy. There was apparent lack of understanding of and regard for the phenomenon of saturation. Examination.of Category IV and requalification training records does not indicate that either before or after licensing did operators receive instruction on the concept of saturation or translation of pressure /temperatere relations to saturation. Training Department staff stated that reactor coolant system thermodynamics were covered in the 9-month Category JV program 158/ but there is no indication of this in records associated with the program. Lack of Understanding of the Need or How to Remove Heat From their actions, neither operators nor supervisory persons who subsequettly reported to the control room demonstrated concern for removing heat from the core or how this might be accomplished. There were indications that operators did not understand the approximate amount of heat being generated in the core from fission production decay and what the consequences might be of not removing this heat. There was no apparent concern for symptoms of core uncovering and loss of effective heat removal capability. Increased nuclear instrument readings were interpreted as symptoms of positive reactivity. Hot leg,, temperatures increasing to off-scale values were dismissed as instrument }]8 malfunctions. 85
In addition to not comprehending the significance of symptoms of dangerous decay heat generation rates, the operators did not demonstrate knowledge of the methods available for heat removal. They did not _ealize that an open relief ve!.ve removes a great amount of heat from the system and shutting that valve without taking compensatory heat removal action will result in higher core temperature. There was no recognition that maintaining the secondary side of the steam generator at essentially the same pressure as in the primary side with both in saturation conditions will result in no heat flow from primary to secon-dary. Again, there is no evidence that training included instruction on decay heat generation rates immediately following a trip and core thermodynamics in general. The Training Department thought core thermo-1 dynamics had been covered adequately in operators' previous (Navy) training. Instructors said that there was some coverage of this subject in the RPS questionnaire in the Category IV program. Examination of the questionnaire does not support the contention. Core thermodynamics were not taught to the operators. Failure to Recognize the Significance of Radiation Levels in Reactor Building Increasing radiation levels in the reactor building observed as early as 19 minutes into the accident followed by numerous radiation alarms were not interpreted by operators as most unusual. Later, very high radiation alarms were not associated with probable damage to the Prompt action was not taken upon the receipt of radiation alarms core. to seal the source of radiation from the environment. In addition, the operators did not seem to understand the significance of increases in gross radiochemistry valves. Review of the training program, again, determines again that in-depth study of radiochemistry and quantitative evaluation of the amounts of radioactivity contained in the core of the reactor at power had not been done as part of training. There had been no exercises involving the calculation of the amount of radioactivity which would be released to the coolant from a fuel failure. Operators in training had not been required to demonstrate by means of calculation the airborne activity and direct radiation resulting from release into containment of normal coolant and coolant-containing fission products. They were not required to have a comprehensive knowledge of radiochemistry. No group problem-solving sessions had been conducted either with operators or health physics personnel to enhance their ability to estimate the likely causes of unusual radioactivity levels and measurements. Summaries of Individual Qualifications The training and qualification record of each licensed reactor operator and senior reactor operator at TMI-2 on March 28, 1979, was reviewed to determine whether the requirements of ANSI 18.1-1971, 10 CFR 55 and the Met Ed requalification program had been met. No significant discrepancies were noted. A summary is provided in Table 4. The qualifications of managers was also reviewed. These are summarized in Table 5. 1183 189
i TABLE 4: Operator Qualifications, Unit 2 A. CONTROL ROOM OPERATORS LICENSE PREVIOUS YEARS YEARS DATE DATE EXPIRATION LAST AT NAME EXPERIENCE EDUCATION EMPLOYED AUX 'A' DATE SIMULATOR o R. R. Booher 6 12 3/18/71 4/5/71 .0/19/79 1/30/79 M. S. Coleman 6 13 1/4/74 1/4/74 10/19/79 3/23/79 J. R. Congdon 7 13 1/7/74 1/18/74 10/19/79 3/16/79 M. V. Cooper 7 14 10/4/76 10/4/76 7/5/80 3/16/79 C. C. Faust 7 13 12/5/73 12/5/73 10/20/79 7/8/77 E. R. Frederick 5 13 11/28/73 11/28/73 10/19/79 7/8/77 H. W. Hartman 6 13 1/28/74 1/28/79 Note 1 3/30/79 E. D. Hemmila 6 15 10/18/76 10/18/76 12/6/80 10/13/78 T. F. Illjes 7 14 2/9/71 4/5/71 10/19/79 7/8/77 J. M. Xidwell 7 12 3/12/74 3/12/74 6/23/80 3/31/78 H. A. McGovern 6 12 10/11/76 10/11/76 12/6/80 10/13/78 D. I. Olson 8 12 3/20/71 4/5/71 6/27/80 5/19/78 L. O. Wright 0 15 3/22/71 4/2/73 10/19/79 7/8/77 1183 190 87
160 TABl.E 4 Operator Qualifications Unit 2 B. SillFT FOREllEN (SRO UNIT 2) 1.lCENSE PREVIOUS EXPERIENCE EDUCATION DATE DATE DATE DATE EXPIRATION LAST TIME NAME YRS "VARS EMPLOYED AUX 'A' CR0 FORENAN DATE SlHUI.ATOR C. D. Adams 8 12 10/6/75 NA NA 10/6/75 10/19/75 3/16/79 W. T. Conausy 6 13 3/23/70 3/23/70 8/11/75 3/1/78 5/3/80 7/8/77 C. L. Gutierie 9 12 2/2/71 UNIC UNIC 3/1/73 8/1/79 1/12/79 ))^ K. H. liyot to 12 4/2/71 4/5/71 8/11/75 5/9/77 10/19/79 3/30/79 A. W. Ililler 0 16 4/4/73 4/4/73 8/11/75 8/1/78 9/1/80 3/23/79 f F. .l. Scheimann 8 12 3/5/73 3/5/73 8/11/75 2/13/78 5/3/80 7/8/77 ~L) 9
161 Table 4 Operator Qualifications Unit 2 C. SilIFT SilPERVISORS (CROSS 1.ICENSED SRO) PitEVIOUS !.lCENSE EXPERIENCE EDtlCATION DATE DATE DATE DATE DATE EXPIRATION I.AST Title NAME YRS YEARS EMPLOYED AUX 'A' CR0 FOREMAN SUPERVISOR DATE SitillLATOR K. P. liryan 11 12 7/10/67 10/20/69 7/28/75 10/1/75 9/27/80 1/12/79 CO L'" J. J. Chwastyk IINK 12 6/17/68 2/23/80 1/26/79 ~}{ C. lii s e 0 12 3/11/69 7/13/70 10/13/75 10/1/77 9/27/80 3/23/79 R. S. Ilutchison 6 15 4/2/73 4/2/73 B/11/75 8/11/75 3/1/79 2/21/81 1/26/19 II. A. !!ehler 2 12 5/9/67 10/20/69 8/23/76 4/1/78 10/19/79 2/5/79 11. G. Sin i t h 9 12 10/27/58 9/1/74 8/2/80 1/20/79 W. 11. Zewe 6 12 2/14/72 10/1/73 5/15//6 I/29/79 1/19/19
TABLE 5 Metropolitan Edison Managers Qualifications NUCLEAR EXPERIENCE NAME POSI110N DEGREE (S) YEARS LICENSE J.G. Herbein V.P. Generation BS 16 NO L.L. Lawyer Manager Generation Operations BS 22 NO G.P. Miller Station Superintendent BS 14 NO J.L. Seelinger Unit 1 Superintendent BSMS 11 SRO J.B. Logan Unit 1 Superintendent BS 20 SRO R.W. Dubiel Supervisor-Radiation Pro-ject Chemistry BSMS 8 NO M.J. Ross Supervisor Operations Unit 1 NONE 14 SRO J.R. Floyd Supervisor Operations Unit 2 BS UNK SFO W.E. Potts Superintendent Tech. Services Unit 1 BS 9 NO G.A. Kunder Superintendent Tech. Services Unit 2 BS 9 SRO W. Marshall Operations Engineer BS 7 SRO H. Shipman Operations Engineer BS 11 SRO D. Berry Operations Engineer BS 15 NO C. Seitz Operations Engineer BS 5 NO T.L. Mulleavy Radiation Protection Supervisor NONE 18 NG D.M. Shovlin Superintendent of Maintenance NONE 6 NO R.E. Sieglitz Supervisor of Maintenance Unit 2 BS 12 NO 1183 193 90
PURCHASE ORDER COURSE DATE COST 43495 CH 2 add two one-week CRO cystem maintenance prog. 12/10/73 10,700 43495 Ch 3 add two two-week radio-chemistry course 2/11, 2/25/74 25,000 12671 Six equal program / year 17,600 ea. One replauement operater/ year 3/13/7.5 16,800 Total Annual '122,400 e 12671 Ch 1 add radiochemistry supervision, two-week 2,500 12671 Ch 2 add radiochemistry supervisor, two week 2,500 12671 Ch 2 add 9 cold license (8 weeks) Jan-Mar 76 132,000 Add 4 cold license (8 weeks) May-Jul 76 58,520 12671 Ch 3 add sim train. for 5 engineers Nov 75 20,400 ea. add sim train, for 5 engineers Dec 75 20,400 ea. 12672 Amend 1 Reduced commitent for training services 1977. Defined Rate of Efforts as follows: 1975 122,400 1976 122,400 1977 ~5:200 1978 123,200 1979 123,200 12671 Ch 7 two week startup cert. 11/1/76, 11/5/76 11/15/76, 11/19/76 4,A00/ lot 12671 Ch 9 add one 8-week cold license course 1/10/77-3/4/77 UNKNOWN 12671 Ch 10 add five-week cold lencese 6/16/77-7/8/78 106,510 12671 Ch 11 add one two-week startup certs. 21,200 Ch 12 add 4 days of operator 7/20/72 & classroom training at TMI 8/1/77 10,200 12671 Ch 13 add two 2-week cold chemistry for radio-chemistry technicians 8/1/77 28,850 l' 1)33 194
PURCHASE DATE COST ORDER COURSE 12671 Ch 14 add one two-week startup 10/31/77 UNKNOWN cert. course 12671 Ch 15 add 5 videotypes, 20 UNKNOWN instruction manuals 12671 Ch 16 add 5 week indoc 1/16/78 UNKNOWN 12671 Ch 18 add 2 week startup cert. 11/9/78 UNKNOWN 12671 Ch 19 add 2 week startup cert. 11/9/78 UNKNOWN 1183 195 92
REFERENCES 1. General Accounting Office Report EMD-79-67, May 15, 1979 2. NUREG-0325, Functional Organization 3. Nuclear Regulatory Commission, Inspection and Enforcement Manual 4. NUREG-0094, Operator Licensing Guide 5. Babcock & Wilcox Training Services Catalog 6. Title 10, code of Federal Regulations, Part 50 7. Title 10, Code of Federal Regulations, Part 55 8. Nuclear Regulatory Commission, Regulatory Guide 1.8 9. American National Standards Institute Standard 18.1-1971 10. American National Standards Institute Standard 3.1-1978 11. Three Mile Island Nuclear Station Safety Evaluation Report P 12. Three Mile Island Nuclear Station Final Safety Analysis Report 13. Three Mile Island Nuclear Station Operating License Technical Specifications 14. Babcock & Wilcox, Limits and Precautions 93 1183 19 fi
VI. FINDINGS Analysis of the selection, training, qualification, licensing, and staffing of Three Mile Island operating personnel suggerts the following findings: There is no regulation concerning the minimum eligibility requirements for 1. either reactor operators or senior reacter operators. 2. The NRC has not prescribed any training requirements for the qualification of operators. 3. The NRC has not prescribed any requirements concerning the education, experience, reliability, skill, stress fitness, psychologi.;al fitness, or criminal records of managers, supervisors, Operators, tecfmic4ans or repair personnel of nuclear power plants. 4. The NRC has not prescribed any requirements concerning the experience levels of operators prior to their being licensed. 5. An operator of a nuclear power plant need not be a high school graduate. 6. No management personnel other than the operations manager require operator's licenses. 7. The minimum required shift composition for operation of TMI-2 while the reactor is at power is one senior operator, two operators, and two non-licensed operators. Only one operator need be in the control room. 8. The examining and licensing of operators is solely the responsibility of the chief of the Operator Licensing Branch of the NRC. 9. Regulations do not require a comprehensive level of knowledge of reactor operators or senior reactor operators. 10. A candidete for an operator's license need not actually conduct a reactor star *up and snutdown to obtain the license. He need not demonstrate the ability to respond to emergency situations. The program for training and qualification of auxiliary operators at TMI is 11. not defined formally. 1183 197
12. There is no formal program at TMI for training shift foremen or shift supervisors. 13. The Babcock & Wilcox Training Department does not have a formal program. 14. The NRC has no requirements concerning the qualifications of engineers and managers. 15. Auxiliary operators who can affect reactor power level and who handle radioactive material are not subject to any regulatory requirements. 16. The regulations do not address any aspects of the licensing process other than a written examination and operating test. 5 17. The NRC licensing process institutionalizes a shallow level of operator knowledge. 18. The NRC conducts a paper review of licensee training programs and a one-time-only review of simulator training programs. 19. The NRC has no formal criteria concerning licensee or B&W instructor qualifications. 20. The NRC does n:t conduct in-depth reviews of licensee or simulator training programs. 21. The NRC has no objection to the licensee or B&W teaching the NRC licensing exam; ' mock' exams are encouraged. 22. Most examiners who prepare and administer operator license examinations do not themselves have reactor operating experience. 23. A person can fail several categories of the NRC operator licensing exam and still pass overall. 24. No candidate for a reactor operator license at TMI since 1974 has failed an NRC licensing examination; 88 percent of senior reactor operator candidates have passed on the first attempt. 25. The Operator Licensing Branch of the NRC is not audited by other parts of the NRC. 26. Once a person is licensed by the NRC he will not, except in rare cases, be again examined by the NRC as long as he participates in a company-administered requalification program. 27. The Operator Licensing Branch of the NRC is understaffed and overworked and has not been given the attention that is merited. 28. Babcock & Wilcox performs a crucial role in training operators for utilties which do not have a simulator. 29. B&W instructors are not required to requalify as operators. 30. The B&W Training Service section has functioned almost independently of both the B&W management and engineering as far as course content and conduct are concerned. } k )h 95
- 31. There is a lack of interaction between plant designers and training personnel at B&W.
32. Few senior engineers at B&W have any first-hand experience with nuclear reactor operations.
- 33. Met Ed management had not observed training of their operators at B&W.
34. Many deficencies exist in the administration of courses at B&W such as not factoring into the program transients from operating plants, lack of syllabi, and lack of training manuals.
- 35. The B&W simulator was unable to reproduce the TMI-2 accident sequence prior to March 28, 1979.
36. Evaluations and drills conducted on the simulator at B&W have not trained operators to cope with major casualties. Trainees' performance on the B&W simulator was not evaluated although this 37 is the only cpportunity available to determine if an operator is competent to function during a emergency. Training at B&W did not instruct operators on how to deal with a small-break 38. LOCA in the steam space of a pressurizer. This was the TMI-2 accident cause and had been the subject of much concern among B&W engineers following a similar transient at Davis-Besse 1 in Toledo, Ohio. Babcock & Wilcox did not instruct trainees one way or another about allowing 39. the pressurizer to go solid when the reactor is shut down. Training which operators received at Three Mile Island did not prepare them 40. to cope with the accident on March 28, 1979. 41. The TMI Training Department is understaffed in terms of quality and quantity. The supervisor of training has been unable to obtain an operator license in over 5 years of trying. 42. Management at Three Mile Island has not been involved in, nor has it considered itself responsible for, training of operators. 43. The Training Department reports to Met Ed headquarters in Reading, Pa., not to site management. 44. There have been many changes of head of training. 45. Shif t foremen who are responsible for operator training are unable to give adequate attention to this task. 46. Auxiliary operator training is sporadic and ill-defined, and does nct cover material needed by these persons to carry out their jobs. Only about 30 percent of the time allotted to training weeks is used for 47. training of auxiliary operators. Replacement operator training is not formally approved and is done on a 48. self-study basis. 1183 199 96
49. The Three Mile Island operator requalification program is of low quality; the material covered is shallow, does not include topics required by 10 CFR 55, and is not related principally to ensuring safe reactor operation. Absenteeism is high. 50. The TMI-2 training program did not teach operators about: pressurizer level versus reactor coolant system pressure; a. b. recognition of saturation conditions; recognition of the need to remove decay heat and how to do it; c. d. recognition of the significance of high radiation levels; or e. recognition of a loss-of-coolant accident. w 1183 200 97}}