ML19308C214
| ML19308C214 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 07/24/1979 |
| From: | Chipman G NRC - NRC THREE MILE ISLAND TASK FORCE |
| To: | NRC - NRC THREE MILE ISLAND TASK FORCE |
| References | |
| TASK-TF, TASK-TMR NUDOCS 8001210547 | |
| Download: ML19308C214 (10) | |
Text
- - - -
- r. (. -
5
? q y $~$
3.........................
...,cd
....C.h.............!
7 79
=9
.l em >
- .c monu m o.m uncu one
- u..**=====~'='~~=~a~"""'"*
1.A 8001210 fff M
H+ 5ek 7'xc L Aree 795K. d UTL/NGS HUMAN FACTORS EVALUATION OF CONTROL ROOM DESIGN AND OPERATOR PERFORMANCE AT TMI-2
===1.
Background===
Following the accident at Three Mile Island Unit No. 2, the Comission established a Special Inquiry to assure that the NRC will have the fullest possible understanding of the events at Three Mile Island. The purpose of that evaluation is to take whatever further steps may be necessary to prevent any similar accident in the future. A major area of investigation by the Special Inquiry is the response of the operating personnel to the events.
Specifically, the Inquiry must determine to what extent the control room design, operator training and selection, operator performance, and other factors, significantly influenced the sequence of events. The work scope described below is essential to the completion of this objective.
l i
II.
Special Inquiry Group Tasks
.g
?%
A.
Operatorsl/
l 8
o Examine background and experience prior to Met Ed employment
[(j(,
o Determine educational background o Identify NRC requirements for selection 7g 4
y%
o Identify Met Ed requirements for selection
-4 o Identify application of selection requirements to operators
-)f30 o
Identify NRC training requirements
[(,
o Identify Met Ed training program / requirements 1
.-?
P (p o Determine formal training of. TMI-2 operators Curriculum Lecture training Simulator training Instructor background Performance of trainee Recurring training l
1[ Operators include:
CR operators, CR supervisors, plant auxiliary operators (Maint. Personnel) and appropriate management personnel.
. Y L 'mihM o Determine on job training for operators V20 G~(Atht.
Caration Fomality of program Capability of instructor (s)
Performance of trainee 4
if o Evaluate training program Other utilities' program a domparison with Met Ed
""C ' i
..: f ; ".:w i n ~ +-
An Na te Ag2c
- /j l 0u nPerformance of operators in meeting requirements (testresults,etc.)
o Actions / Inactions before the accident Identify critical system malfunctions / misalignments Identify human factors involvement in system malfunctions p -- Determine when and how recognition of malfunction was achieved
- -- Determine when and how correction of the malfunctions was achieved
~3 o Actions / Inactions during accident 7/30 Determine detailed sequens of events j/so Ioentify significant opernor actions / inactions B.
Precursors related to Human Factors o Identify significant precursors that could have impacted TMI-2 o Determine the response to each of these significant precursors o For each precursor, determine what information was gained /should have been gained o Determine what information feedback was utilized To update training To update procedures To update plant To update control room Other l
l l
l
o Compare emphasis on precursor events by Met Ed and other utilities -t ewnMessenes lent anly C.
Control Room Design 2-7/Jo o
Identify NRC regulations and regulatory guides i
2-7 /.7o Identify published standards and recomended practices of o
j other organizations 1
d(,
o Identify the criteria utilized in TMI-2 CR design 1
T/6 decumfro Identify the CR design philosophy NRC philosophy Met Ed philosophy Vendor philosophy Architect / Engineer philosophy 2.
- o Determine the dominant influence on TMI-2 CR design 2
- o Evaluate the conformance of CR design t.o human engineering principles 2
- o Compare design process to that utilized in other CR's of the same vintage 2
- o Evaluate the human factors considerations utilized in design of critical systems, controls and procedures 2
- o Compare CR design (from a human factors viewpoint) with designs of other complex man / machine systems NASA D0D Chemical Industry M
o Dc Y b/2 c4toigfJ (Jost-ac.c4ht D.
Plant Design & Control (outside CR) c- \\3 o Identify NRC requirements for plant design and control c
related to human factors Reactor and secondary system o
o Identify Met Ed influence on design
- These evaluations are to be performed in conjunction with the contractor.
l l
_ m o For plant control other than CR, determine 2.j,0 Human factors application Communication Signals in CR E.
Procedures
- 7.
Pf k decow* fro Determine process for development of emergency procedures P(20 peces By whom Review and/or approval Update in light of precursors o Evaluate effectiveness in time of emergency *
- 2_
o Evaluate effectiveness in TMI-2 accident 1.
o Evaluate operators' use of procedures
- 2.
o Examine need for simplification of procedures
//
F.
- Evaluate in conjunction with contractor, the adequacy of the following, particularly as they related to the accident
/- t o NRC requirements o Met Ed & their contractors and vendors in applying human 4
factors principles o Operator selection and training 6 2, p.
o Control room design t
/ o Feedback of information from precursors o Plant design p
f-o Emergency procedures
- These evaluations are to be performed in conjunction with the contractor.
. l III.
Outside Contractor Tasks Task A - Control Room Design at TMI-2 The Contractor shall:
1.
Identify the criteria which directly influenced the CR design as specified by the NRC and standards organizations.
a.
Review Title 10 of the Code of Federal Regulations, NRC Regulatory Guides and Standard Review Plans as provided by the NRC which dictated the design of the control room and point out those criteria which require the application of human engineering principals to such designs, b.
Identify relevant standards and recomended practices published by organizations other than NRC which deal with nuclear power plant control room design.
Identify which of the criteria identified in 1.b. were c.
utilized in the design of the TMI-2 control room.
2.
Identify the actual design basis and operating logic which led to the as-built design of the control room.
Review the design studies and analyses of Metropolitan Edison Co. and its associates as provided by the NRC leading to as-built design of the control room and deter-mine what human engineering principles were applied, i
l l
6-3.
Determine if the CR was designed in accordance with the design basis and criteria identified in 1 and 2 above.
a.
Review control room contractual documents, Final Safety Analysis Report, Construction specifications and as-built drawing as pro-vided by the NRC to determine the human factors aspects of the' con-trol room design.
b.
Visit Three Mile Island site for familiarization and to complete accurate description of the control room in its pre-accident con-figuration.
In conjunction with the NRC Special Inquiry contract project manager c*
("NRC project manager") compare the human factors aspects of the actual design of the control room (as determined under 3 a and b above) with the criteria and bases that led to the design (as determined under 1 and 2 above).
d.
In conjunction with the NRC project manager, and using the results of 3.c., identify those implicit philosophical or broad based design concepts which had a significant impact on the human fcetors design of the control room (i.e. single failure concept).
e.
Determine if the quantity and prominance of information presented in the control room are consistent with the design bases and criteria.
4.
Compare the design process for TMI-2 CR with that used in other nuclear plant control rooms of the same vintage.
a.
In conjunction with the NRC project manager, identify a limited number of plants (at least 2) of the same generation as TMI-2.
b.
Obtain reconnaissance level information (documents and discussions) on human factors criteria and design bases used.
c.
Visit the control rooms identified above, and assess the degree to which these designs were 6onstructed in accordance with their respec-tive criteria.
NRC will assist contractor in obtaining access to such control rooms.
- d. On a broad basis and in conjunction with the NRC project manager, compare the process that resulted in the application of human l
engineering principles to the design of the control room of TMI-2 with that of the plants identified in 4.a above.
A
mns - Kontral Rma Activitv T5eContractorshall:
1.
Construct a full scale mock-up of the TMI-2 control room panels utilizing photographs for the panels identified in the table below.
The mock-up must be transportable in sections.
Drawings of the panels will be provided by NRC in conjunction with Task A.3.b.
Visit the TMI-2 CR to provide familiarity with the actual CR layout.
2.
Prepare a timeline diagram of the control room activities during the first 150 minutes of the accident.
a.
Using event chronologies and operatorinterviews provided by NRC, define operator activities.
b.
NRC will identify the critical timeline actions / inactions within the control room which significantly influenced the outcome of the accident.
3.
Video tape an enactment of the timeline sequence of events for use in the analysis of operator perfonnance.
4.
Based on the emergency procedures and other fonnal guidance available to the operators, develop an idealized timeline.
5.
In conjunction with the NRC project manager, identify the control room design factors which influenced critical actions / inactions (2.b. above).
Emphasis should be placed on the most significant human engineering issues.
Table of Control Room Panels to be Modeled 4
Control Room Desk - CONS-1 Computer Console - CONS-2 Aux. Systems Control Console - CONS-3 Plant Control Console - CONS-4 Turbine Control Console - CONS-5' Electric Control Consoles - CONS-6A, 6B, 6C Fire Detection Panel - PNL-7 Coolant Systems Monitoring Panel - PNL-8 Reactor Coolant Drain Tank Panel - PNL-8A Push Pull Control Panel - PNL-9 Plant Equipment Temp. Recording Panel - PNL-10 Radiation Monitoring Panel - PNL-12 SFAS Panel - PNL-13 Control Rod Drive Panel - PNL-14 Containment Isolation Panel - PNL-15 Turbine Supervisory Panel - PNL-16 Turbine Auxiliary Monitoring Panel - PNL-17 Station Electric Aux. Monitoring Panel - PNL-18 Vital Power Panel - PNL-19 l
Nuclear Instrumentation - CAB-20, 21 HVAC Panel - PNL-25 Diesel Generator No.1 & 2 Panels - PNL-26, 29 Computer Programmers Console - CAB-188A
(
The Contractor shall:
1.
Detemine the adequacy of the training program to assure the operators' capability to diagnose problems and take appropriate actions during normal and emergency conditions, a.
NRC will provide documents describing operator training program, TMI-2 emergency operating procedures and will make available NRC operator licensing personnel to describe the regulatory program.
b.
In conjunction with the NRC project manager, detemine if the operator training was adequate in particular with respect to the significant actions / inactions taken by the operators on the THI-2 accident.
2.
Identify the basis for each significant action / inaction resulting from operator perfomance that cannot be attributed to inadegaate training.
Where additional interviews with operators are required, this will be arranged through the NRC project manager.
Types of results that might be obtained include:
mismatched operator aptitude, poorly defined lines of authority or task assignments within the CR, etc.
3.
Evaluate the adequacy of the transfer of infomation between shifts, and between operators and maintenance personnel at TMI.
Review NRC and Het Ed l
requirements for infomation transfer and the implementation of these require-ments at TMI-2.
Compare the information transfer procedures of TMI-2 with those used in the plants identified in Task A.4.a. above.
Task D - Acolication of Human Factors Principles to Control Room Design The Contractor shall:
1.
Identify the systems components and procedures in the control room which played a critical role during the first 150 minutes of the accident.
NRC will identify the critical timeline actions / inactions (critical points) a.
l within the control room which significantly influenced the outcome of the accident (B.2.b.) and provide applicable emergency procedures (C.l.a).
b.
For each critical point, identify the systems, components and procedures in the control room which did or should have played a role in the decision process.
NRC will provide documentation of the chronology of events and existing c.
operator interviews as necessary.
Requirements for additional interviews will be coordinated through the NRC contract manager.
2.
For each critical system, component and procedures identified in 1 above, identify the relevant human factors considerations.
This will include the factors in the relevant Human Factors engineering standards.
3.
Detemine the degree of compliance of the critical system and component designs and procedures to the applicable human factors principles (standards).
4.
Where areas of non-compliance are identified in 3 above, in conjunction with l
the NRC project manager, determine the impact on operator perfomance at critical points.
,of 50 Utilizing the information obtained in Task A and B and in 1-4 above, J
and in conjunction with the NRC project manager, evaluate the inte-gration of the control room design with the reactor system design in the context e" human factor program development.
This should include l
the utilizatr 1 of task analyses of:
the role of the CR operator; l
generating Ck :taff selection and training requirements; development and testing of operational procedures (including emergency actions);
and the effectiveness of Licensee Event Reports (LERs) feedba'k.
c 6.
Identify the approach taken by other agencies and organizations in the design of comparable complex man / machine systems with respect to the application of human factor principles and one example of advanced CR design concept being offered by a U.S. nuclear plant supplier.
The agencies and organizations investigated should include comparable industries (chemical, etc.), the amed services and NASA.
The procedural'and decision-making process employed by each selected organization will be compared to the process utilized in the design of 1NI-2.
Significant variations should be identified and their impact on the perfomance of the operation estimated in conjunction with the NRC managers.
8V.
Deliverables
- 1. For all tasks A-D a.
Letter status reports every 2 weeks.
I b.
Preliminary final letter report of all findings by September 28, 1979.
t NRC will provide coments by October 3,1979 and Final Letter report c.
of all findingt incorporating NRC comments by October 10, 1979.
- 2. Contractor may be required to deliver the CR mock-up to the Washington.
DC, metropolitan area before the termination of the contract.
If the mock-up is not requested by the NRC by contract temination, the contractor may dispose of the mock-up.
- 3. The contractor shall be available to brief NRC Comissioners and other groups (not to exceed 10 briefings or hearings) regarding their work and findings on an as needed basis.
- 4. Except as specifically authorized by this contract, or as otherwise approved by the Contracting Officer, records er other information, documents and material furnishing by the Comission to the Contractor in the perfomance j
of this contract shall be used only in connection with the work performed 1
i under this contract.
The Contractor shall, upon comple. tion or termination of this contract, transmit to the Comission all records or other infomation, documents and material, and any copies thereof, furnished by the Comission to the Contractor or data developed by the Contractor in the performance of this contract.
j