05000334/LER-1980-087-03, /03L-0:on 801113,operator Attempted to Perform Operation Surveillance Test on Intermediate Range Nuclear Instrument While Reactor Was Critical.Caused by Operator Error & Possible Inadequate Situational Analysis Guidance

/03L-0:on 801113,operator Attempted to Perform Operation Surveillance Test on Intermediate Range Nuclear Instrument While Reactor Was Critical.Caused by Operator Error & Possible Inadequate Situational Analysis Guidance

ML20002B055
Person / Time
Site:	Beaver Valley
Issue date:	11/25/1980
From:	Lacey W DUQUESNE LIGHT CO.
To:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
Shared Package
ML20002B052	List: 05000334/LER-1980-087, Forwards LER 80-087/03L-0 05000334/LER-1980-087-03, /03L-0:on 801113,operator Attempted to Perform Operation Surveillance Test on Intermediate Range Nuclear Instrument While Reactor Was Critical.Caused by Operator Error & Possible Inadequate Situational Analysis Guidance
References
LER-80-087-03L, LER-80-87-3L, NUDOCS 8012090392
Download: ML20002B055 (6)

LER-1980-087, /03L-0:on 801113,operator Attempted to Perform Operation Surveillance Test on Intermediate Range Nuclear Instrument While Reactor Was Critical.Caused by Operator Error & Possible Inadequate Situational Analysis Guidance

Event date:
Report date:
3341980087R03 - NRC Website

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EVENT DESCRIPr!ON AND PA08 A8LE CONSEQUENCES h gl An operator tried to do an (OST) Oncration Surve111nnce Tose on an intermedinte I

gl Range nucicar instrument. The operator then realized he couldn't do the test I

lTT;n I because the reactor was critical and power level was too hich. The ense,e ate I

gog3; g tihe was in progress with the channel in bypass which is the way it was left until I g g approximately nine hours later. The power rance low setpoint t. rips were avati nble !

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Attachment To LER 80-087/03L~

4 Beaver Valley Power Station Duquesne Light Company Decket No. 50-334 The apparent generic attitude and understanding problems associated with this incident appear to be the root cause of incidents of this nature.

In order to adequately address and analyze this aspect, a planned course of analysis action was developed by the senior station staff, discussed with the Resident NRC Inspector (D. A.-Beckman) and implemented on November 17, 1980.

This plan consists of the following major phases:

1) Participatory involvement of all licensed operating personnel and Shift Technical Advisors in the analysis, evaluation and actions to be taken to resolve the root problem. A letter (copy attached) was issued on November 17, 1980 requesting dit et and individual input to the Station Superintendent on this subject.

2) Review of existing Station Administrative Procedures, Operating Manual Procedures and Training Program content by Senior Station Management staf f for any necessary changes or additions, t

3) Review of the inputs from item (1) above to formulate:

a.

Specific long term actions to preclude future occurrence b.

Assessment of individual attitude / understanding by critical analysis of responses

4) Development.and implementation of necessary programs to resolve any definite or implied attitude and understanding problems which be indicated by the analysis of the responses noted in (3b) above.

These may include:

- Motivational Training J

- Increased management surveillances

- Human factors train'ing

- Communication skills training

- Constructive Quality Concept training

- Feedback and Assessment Programs 5)

In parallel with phases (1) through (4) above, a series of discussion sessions will be conducted by the Station Superintendent with operating personnel. There will be ccheduled on a small group (3-4) basis, consistent with existing operator shift schedule requirements and regulations until all operating personnel h' ave participated. The purpose of these discussions will.be to reinforce the seriousness and ramifications of this type of incident, the reasons leading to and the ways to preclude such occurrences, and as a supplemental method to assess overall attitudes and understanding.

Pending resolution of operator schedules, plant status and vacation / holiday sc'.. :dules, it is anticipated that this discussion series will commence during the veck of November 24, 1980 and require approximitely 6 weeks for completion..

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Attachment To LER 80-087/03L Beaver Valley Power Station Duquesne Light Company Docket No. 50-334 A licensed reactor operator commenced an operational surveillance test that had to be stopped prior to completion. The reason the test had to be stopped was because the reactor was critical and above the test intermediate range power Icyc1 that was supposed to be indicated.

When the operator realized what the problem was he immediately stopped the test, noted the problems and informed his supervisor.

The breakdown in communication happened at this point since the nuclear instrumentation channel was left in " bypass" and not immediately returned to normal service. Because the test was being run late in the shift in conjunction with low power physics testing, there were a number of evolutions taking place. The midnight (2300 - 0700 hours0.0081 days <br />0.194 hours <br />0.00116 weeks <br />2.6635e-4 months <br />) shift reactor operator found the channel in bypass and returned the system to normal. Several administrative procedures were violated during this evolution.

Immediate action taken to prevent reoccurrence consisted of evaluation of the incident with involved personnel by the Station Superintendent and senior station management staff.

Following this, the Station Superintendent personally discussed with all available Shift Supervisors the fact that administrative controls were bypasses and the number of people involved and results of critical questioning of those involved indicated that the problem may be a generic attitude problem.

Each Shift Supervisor was directed to personally discuss the incident with all operating personnel on their shift. On November 17, 1980, a letter was issued by the Station Superintendent to all Shift Supervisors reinterating the above noted directions and requiring documentation of accomplishment, including names and times, to the Station Superintendent within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of receipt of the letter. This same letter was also issued to the Station Technical Advisory Engineer directing him to take the same actions with all Shift Te 'nical Advisors.

In parallel with the above, due to the apparent generic implications, an in-depth evaluation was instituted. This evaluation is identified as follows.

Initial reviews by senior station management, including critical questioning of involved personnel indicate that underlying reasons for this incident may include:

1) Existing Station Administrative Procedures cover this type of situation, however-they may need further clarification to explicitly define all situations involving terminating procedures prior to the " normal" end point.

2) Existing station implementing procedures (Operating manual) - same as (1) above.

3) Present training program appears to need supplementing to include further emphasis on non-technical aspects of operations (e.g. decision-making, responsibilitics, quality applications, management / supervisory processes).

4) A generic problem regarding attitude and total understanding of underlying reasons for formal controls may exist within the operations personnel organization.

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- Attachment To LER 80-087/03L Beaver Valley Power Station Duquesne Light Company Docket No. 50-334

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A supplementary report including results and actions to be taken from 4

this overall prgram will be issued upon completion.

.It is anticipated that j

this report should be available by January 1, 1981.

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DUQUESME !.1CllT COMi'ANY Beaver Valley Power Statlun November 17, 1980 SVPS: JAW:1025 Request For Input To Resolution Of November 13, 1980 IR-NIS Incident To all:" Shift Supervisors Nuclear Control Operators Shift Foremen On November 13, 1980, an incident occurred whereby one channel of the Internediate Range Nucicar Instrumentation System (IR-NIS) was placed in BYPASS mode during the performance of an improperly scheduled OST.

When it was determined that the OST was not required, the OST was terminated; however, restoration of the original initial conditions prior to the start of the OST was not accomplished, thereby leaving the IR-NIS channel in the BYPASS mode with the plant in Mode 2 and the re.ctor critical. This occurred during the 0800-1600 hour shif t and was not discovered until the turnover between the 1600-2400 shift and the 2400-0800 shift. Hence, this condition went unnoticed for one shif t turnover and approximately 1 1/3 shif ts of normal duty.

A similar such incident occurred approximately one year ago resulting in several administrative procedure changes to preclude recurrence.

The occurrence of this November 13, 1980 incident implies either:

1) ineffective administrative controls exist to p,reclude this type of incident; 2) disregarding of existing controls by the personnci involved; or 3) carelessness. With the maCnitude of the responsibility we have as operators of a nuclear facility, none of these conditions are acceptable - either to us or to the public we serve.

Due to the extreme seriousness of this type of incident, it is imperative that we address the solution collectively in order to obtain as cuch input to the solution as possible.

I regard your input, as licensed operators of this station, to be of extreme importance. Therefore, I request that you provide to me your written, individual analysis and reco==endations regarding this incident by return letter. In this =anner, the final decisions made regarding future actions may be made taking into consideration the input fros,those of us who must actually live by the decisions.

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To All 1.leensed l'..it.umnet Novechar 17, 1980 BV PS :.1/.* ': 1025 Par.c 2 l

1.

What. in your opinien, was the underlying root cause of this occurrence?

2.

Should existing administrative procedures be revised, amplified, or expanded to avoid such occurrences?

3.

Would additiona'l training help?

If so, what type?

4.. Is disciplinary action warranted? If so, what and to whom?

If not, why?

5.

Are existing Control Room formalitics and shif t turnover procedures commensurate with the responsibility of the task we have in operating this station?

6.

Arc existinr, attitudes, dedication and concern with safety of the operating staf f (which includes vou) conducive to the philosophy l

that in our business, "merely satisfactory performance is unacceptabla"?

7.

What overall actions do you recommend to resolve the root cause of this occurrence?

Your reply to this icteer is to be made, in writing, before December 1, 1980.

(46-J. A. Werling JAW:ses cc:

C. V. Moore J. J. Carcy H. P. Williams L. C. Schad J. V. Vassello l

J. D. Sieber

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