ML20056H462
| ML20056H462 | |
| Person / Time | |
|---|---|
| Issue date: | 08/03/1993 |
| From: | Barchi T NRC OFFICE OF THE INSPECTOR GENERAL (OIG) |
| To: | |
| References | |
| OIG-93A-09, OIG-93A-9, NUDOCS 9309090372 | |
| Download: ML20056H462 (24) | |
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a OFFICE OFTHE INSPECTOR GENERAL i
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REACTOR RESTART PROCESS 33 OIG/93A-09 August 3,1993 5
AUDIT REPORT
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UNITED STATES l',,s<
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t August 3,1993 OFFICE OF THE INSPECTOR GENERAL MEMORANDUM FOR:
James M. Taylor I
Executive Director for Operations iM. M FROM:
Thomas archi Assistant Inspector General for Audits
SUBJECT:
REVIEW OF NRC'S REACTOR RESTART PROCESS I
I Attached is the Office of the Inspector General's audit report entitled, " Review of NRC's Reactor Restart Process."
I On July 28,1993, the Deputy Executive Director for Nuclear Reactor Regulation, Regional Operations and Research provided comments on our draft report. He agreed with our recommendations and suggested clarifying language for several sections in the report. We I
have reviewed his com.ments and have added clarifying language where we believed appropriate. We agree that his planned corrective actions will satisfy the intent of our recommendations.
Attachment:
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cc:
H. Thompson, EDO J. Sniezek, EDO S. Chilk, SECY W. Parler, OGC D. Rathbun, CA I
T. Murley, NRR E. Jordan, AEOD E. Beckjord, RES I
R. Bernero, NMSS P. Norry, ADM R. Scroggins, OC i
P. Bird, OP i
T. Martin, RI
'g S. Ebneter, RII l
J. Martin, RIII J. Milhoan, RIV B. Faulkenberry, RV I
J. Blaha, EDO J. Funches, ICC I
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Reactor Restart Process
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REPORT SYNOPSIS b
The Office of the Inspector General (OIG) has previously reviewed issues related to a reactor restart and the dual responsibilities of the Nuclear
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Regulatory Commission (NRC) and the Federal Emergency Management Agency (FEMA) for emergency preparedness. In 1991, we issued two audit
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reports on these issues. One report addressed NRC's handling of restart issues for Pilgrim 1, and the other disclosed ambiguities in the relationship between NRC and FEMA.
On August 24,1992, Florida Power and Light (FP&L) shut down its Turkey Point nuclear plants because of impending danger from Hurricane Andrew.
The storm cause extensive damage to the site. With NRC's approval, FP&L restarted Turkey Point Unit 4 on September 29,1992. Two days later, FP&L
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shut down the plant because the restart process failed to adequately consider emergency preparedness issues. In particular, NRC failed to notify the proper FEMA officials of Unit 4's planned restart. We initiated our review to
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evaluate the effectiveness of NRC's overall process for approving reactor restarts and to evaluate what appeared to be contimiing ambiguities in the relationship between the two agencies.
After the Turkey Point Unit 4 restart, NRC management recognized that its restart procedures were inadequate. We found that NRC management has since strengthened the guidance for approving reactor restarts, and is revising its Mema andum of Understanding on emergency preparedness with FEMA to clarify the roles and responsibilities of the agencies. However, we believe i
additional actions are needed to further improve the reactor restart process.
Specifically, we found that, (1) the process for tracking and documenting the resolution of restart issues needs improvement, and (2) NRC and FEMA need to improve communications channels.
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Our report makes recommendations for improving the tracking of and documentation for restart issues, and establishing specific NRC and FEMA points of contact for emergency preparedness issues.
C ow n cL I
Reactor Restart Process TABLE OF CONTENTS I
REPORT SYNOPSIS...............................
i INTRODUCTION.................................
1 B ACKGROUND.............................
1 1~
FIND IN G S.......................................
3 Restart Issue Tracking and Documenting
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Process Needs Improvement.....................
4 NRC and FEMA Need to Establish More Effective Communication Channels................
5 CONCLUSIONS...................................
7 RECOMMENDATION S.............................
8 AGENCY COMMENTS................
8 APPENDICES I
Objectives, Scope, and Methodology II Restart Data Communication Flows III U.S. NRC Organization Chart IV Agency Comments on Draft Report V
Major Contributors To This Report
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I Reactor Restart Precess I
l INTRODUCTION
.g A utility may shut down a licensed commercial nuclear power plant voluntarily, or involuntarily based on an order from the Nuclear Regulatory Commission (NRC). When a plant is shut down for reasons stemming from l
license conditions or technical specifications, the licensee usually can develop and implement a clearly defined corrective action plan, and the plant may restart without approval from the NRC. However, plants are sometimes shut I
down because of safety concerns resulting from a significant event, complex hardware problem, serious management deficiency, or as a result of a natural I
disaster. In these cases, NRC generally reviews a licensee's corrective actions and develops a Restart Action Plan before allowing a plant to restart.
I BACKGROUND During the past several years, NRC has required several nuclear plants to gain its approval prior to restart. These plants include, but are not limited to g
Pilgrim 1, Brunswick 2, Calvert Cliffs 1 and 2, and James A. FitzPatrick.
In 1991, NRC's Office of the Inspector General (OIG) issued two audit l
reports that examined issues related to Pilgrim l's restart.' These issues concerned the closure of restart items and the responsibilities of NRC and the Federal Emergency Management Agency (FEMA) for emergency I
preparedness (EP) matters. One report stated that NRC had closed all restart items identified in three Confirmatory Action Letters (CAL) issued to the l
Boston Edison Company. The other report disclosed ambiguities in the relationship between NRC and FEMA for EP matters.
On August 24,1992, Hurricane Andrew struck southern Florida and caused massive destruction. As a result, Florida Power and Light (FP&L) shut down I
its two nuclear units, Turkey Point Units 3 and 4.
The site sustained substantial damage and Turkey Point lost offsite power and communications.
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'OIG 90A-14, January 16,1991; OIG 91A-01, June 4,1991.
OlG/9Ma9 Pay 1 I
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I lI Reactor Restart Process liowever, there was no release of radiation to the environment. Almost immediately following the storm, NRC and FP&L initiated efforts to restore the site and to plan the restart of Unit 4.2 I
During restart preparations, NRC did not properly consider offsite EP matters. Specifically, NRC permitted Unit 4 to restart without obtaining an assessment of off site EP factors from FEMA. Because of this shortcoming in the restart process, and to determine if ambiguities with the NRC/ FEMA relationship still exist, we initiated this review to evaluate the reactor restart l
process.
NRC and FEMA share EP responsibilities at nuclear reactor sites. NRC is the onsite reviewer, while FEMA evaluates offsite' considerations. These EP responsibilities are mandated by statute and Presidential Directive. After I
considering FEMA's input, NRC makes overall determinations about the 5
adequacy of EP at nuclear reactor sites. NRC and FEMA each have a l
preparedness and response organization for EP issues. Within NRC, the Office of Nuclear Reactor Regulation (NRR) and the Office for Analysis and Evaluation of Operational Data (AEOD) have preparedness and response g
duties, respectively.
3 NRC's responsibilities relating to radiological EP are derived from its licensing functions under the Atomic Energy Act of 1954, as amended, and the Energy Reorganization Act of 1974, as amended. Part 50 of Title 10 of the Code of Federal Reculations (10 CFR Part 50) contains NRC's l
regulations for EP.
FEMA's role in the EP process was incorporated into NRC's regulations in 1980. Sections 50.47 and 50.54 relate to FEMA's involvement with issuing an l
operating license and evaluating EP for operating reactors, respectively, g
These sections require NRC to consider FEMA's findings and determinations in assessing whether (1) State and local emergency plans are adequate, and (2) there is reasonable assurance that they can be implemented.
l 2Unit 3 remained shutdown for refueling after the hurricane passed.
'Offsite refers to the geographical area outside the boundaries of the nuclear plant itself.
l onop3Am rap 2 I
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Reactor Restart Process In 1985, NRC and FEMA signed a Memorandum of Understanding (MOU) on EP to delineate the roles and responsibilities of the two agencies. The agencies are currently revising the MOU on EP to clarify their roles and responsibilities, and to address disaster related situations like Hurricane Andrew. A separate MOU on Incident Response, dated October 22,1980, deals with NRC/ FEMA cooperation and responsibilities in response to an actual or potential radiological emergency.
A description of our objectives, scope, and methodology is contained in Appendix I.
FINDINGS We found that NRC issued restart criteria in 1988 and a restart manual chapter in 1990.
However, the 1990 manual chapter lacked detailed procedures to ensure that relevant issues were addressed during reactor restarts. During the audit, this manual chapter was revised (January 1993),
and issued as NRC Inspection Manual Chapter (MC) 0350. It was developed from the " lessons-learned" following the Turkey Point Unit 4 restart experience, and we believe the revised guidance establishes a systematic approach for planning reactor restarts.
The recently revised guidance includes, for the first time, an individual checklist item for EP. However, the new guidance does not establish a definitive process for tracking and documenting the resolution of restart issues.
Although NRC has taken several positive actions to develop and improve reactor restart criteria, including EP considerations, we believe that additional actions would further improve the restart process. Specifically, we found that:
The process for tracking and documenting the resolution of restart issues needs improvement.
NRC and FEMA need to establish more effective communication channels.
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RESTART ISSUE TRACKING AND DOCUMENTING PROCESS NEEDS IMPROVEMENT We found that the process for tracking and documenting restart issue g
resolution is not adequate. Specifically, while the recently revised hic 0350, 3
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" Staff Guidelines For Restart Approval," establishes guidance for developing i
a Restart Action Plan, it does not provide detailed guidance for tracking and documenting the resolution of restart issues.
The purpose of hic 0350 is to (1) establish restart guidelines after a voluntary l
or involuntary shutdown resulting from a significant event, complex hardware problem, serious management deficiency or natural disaster, (2) provide a E'
generic checklist for plant-specific Restart Action Plans, and (3) record major 3
j regulatory actions for restart approval. Plants subject to the restart guid: lines contained in hic 0350 have often been those plants that were been placed on NRC's Watch List of plants needing close attention.
The revised manual chapter includes checklists to identify restart tasks l
applicable to a specific case. Starting with a review of these tasks, the staff develops a detailed inventory of the plant-specific restart issues. An issues g
inventory may arise directly from the causes for shutdown, licensee reviews, 5
l and other sources, such as NRC inspection reports or special evaluations.
While the manual chapter also discusses issue tracking in a general fashion, l
it does not establish a specific process for tracking and documenting the l
resolution of plant-specific restart issues.
AfC 0350, section 06.02, for l.
example, states that a Restart Action Plan should include all expected NRC actions necessary prior to restart, and who has lead responsibility for each g
action. However, it is not clear whether "who" refers to an individual or 5
organization. Although Appendix A states that a restart panel should " verify necessary tasks and items are complete for each phase of the review...",it does g
i not require cross-references to the documentation used to close each issue.
To properly account for the " work-in-progress" issues inventory, we believe l'
that all restart plans should contain basic tracking information for each restart issue. This information was included by restart managers for several cases.
g Each issue should then be included in the restart authorization document to 5
4 track its resolution and closure. In particular, we noted that the tracking g;!
process for the 1993 FitzPatrick restart contained detailed information to onopum ray: 4 I
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Reactor Restart Process track restart issues. This information included (1) an assignmen'. number to provide an internal control for tracking and resolving each issue, (2) an official designated for follow-up and resolution, (3) a closeout reference (e.g.,
an inspection report number), and (4) the date the issue is closed. Some of this information was also included for other restarts we examined. While this tracking process appears to have been effective, it relied on the individual management skills of the restart managers, rather than on an effective systematic process and management oversight.
We are concerned that the current guidance will not provide a sufficient audit trail to assure NRC, the Congress, and other interested parties that all restart issues are resolved. In 1990, a public citizen group alleged that Pilgrim l's restart requirements related to a CAL were not resolved prior to restart.
While we confirmed that all CAL issues were resolved, the rbsence of a clearly defined audit trail for each issue made the task difficult. One issue, in particular, had several subparts which were not discretely tracked to close the specific CAL issue.
NRC AND FEMA NEED TO ESTABLISII MORE EFTECTIVE COMMUNICATION CIIANNELS Our review disclosed continuing ambiguities in NRC's implementation of its MOU on EP with FEMA. These ambiguities created questions about NRC's performance when it authorized Pilgrim l's restart in 1988, and recently contributed to miscommunications between NRC and FEMA that resulted in a flawed restart process for Turkey Point Unit 4 (1992). Consequently, the plant shut down 2 days after its restart.
The 1985 MOU on EP between FEMA and NRC clearly states that NRC has responsibility for onsite EP concerns, while FEMA is responsibie for offsite EP concerns. During the 1988 Pilgrim 1 restart preparations, however, NRC initiated its own review of offsite EP because FEMA was unable to meet the projected restart schedule.
Our January 1991 report on EP issues questioned NRC's authority to perform offsite EP reviews. While NRC stated that the Atomic Energy Act gave it the authority to perform such reviews, NRC agreed to revise the NRC/ FEMA OlG/9E09 Page5
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1 Reactor Restart Process MOU to clarify the roles and responsibilities of the agencies. A revised MOU l
has been s:nt to FEMA for signature.
On September 29,1997, Turkey Point Unit 4 restarted after being shut down for approxima:dy 5 weeks due to onsite and offsite storm damage from Hurricane Andrew. Our review determined that NRC did not notify the g
FEMA preparedness organization of the projected restart date for Turkey Point Unit 4; rather, NRC notified FEMA's prenaredness staff after the reactor restarted. On October 1,1992, following discussions between FP&L, ll FEMA, and the NRC, FP&L shut down the reactor pending FEMA's further consideration of the status of EP. This action was taken even though FEMA B
had not withdrawn its approval for offsite EP. To assess why NRC did not 5
communicate the restart date sooner, we examined the process and the documentation leading to restart on September 29,1992.
g After the hurricane struck on August 24,1992, much of southern Florida and the EP area around Turkey Point was devastated. However, FEMA did not l'
withdraw its reasonable assurance finding concerning the adequacy of offsite EP. According to FEMA officials, NRC staff told them that the plant would g
not restart for several months. FEMA officials advised us that this timeframe 5
gave them the opportunity to reassess EP later.
On August 31,1992, FP&L advised NRC Region II (Atlanta) that Turkey Point Unit 4 would restart in approximately 30 days. Although NRR's reactor projects management staff received this information, NRR's EP l
management staff did not.
AEOD, NRC's response organization, also j
received this information and forwarded it to FEMA's response organization gl for inclusion into FEMA's situation reports. FEMA Situation Report 16, 5 '
dated September 2,1992, notes that Turkey Point Unit 4 was expected to restart within approximately 30 days. FEMA Situation Report 19, dated l
September 5,1992, contains the same restart estimate. Neither NRC nor FEMA officials notified FEMA's preparedness staff of the anticipated restart l
date.
FEMA preparedness ot'ficials advised us that NRC did not provide the specific E
restart date, and became aware of the restart only after it occurred.
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Therefore, we believe that Turkey Point Unit 4's premature restart and shutdown 2 days later was partly caused by NRC's failure to adequately g
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Reactor Restart Process f
inform its own officials and the proper FEMA officials.
NRR and Region II prepared reports that addressed deficiencies in the restart process based an lessons learned from the Turkey Point Unit 4 restart.
Although these i eports made several recommendations for improving internal communications, and addressing EP issues, they did not address the dual flow of information from NRR and AEOD to FEMA.
We believe that NRC and FEMA need to estabEsh better channels of communication to facilitate information flow between their respective organizations.
An improved communications process may avert future problems similar to the Turkey Point Unit 4 restart experience. Appendix II shows the communication flow that existed during the Turkey Point Unit 4 restart, and a suggested revised flow to ensure that all appropriate NRC and FEMA organizations are aware of restart data in a timely fashion.
CONCLUSIONS Recent improvements to the reactor restart process have strengthened the procedures needed to ensure that NRC and utilities address restart issues.
While the revised process establishes a systematic approach for planning reactor restarts, it does not provide an adequate process for tracking and documenting the resolution of restart issues. The process used to track restart issues depends heavily on an individual's management skills instead of on an effective, systematic process combined with effective management oversight.
Although NRC is currently revising its MOU on EP with FEMA to address and clarify the EP concerns stemming from the Pilgrim 1 and Turkey Point Unit 4 restarts, we believe some ambiguity still exists regarding the communication of EP information. Although vital restart information was transmitted between the two agencies following Hurricane Andrew, it was not sent to the FEMA office that needed it most, its preparedness organization.
We believe that NRC and FEMA need to further improve their channels of communication to ensure that each agency receives information necessary to discharge effectively their respective EP responsibilities.
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OlG/ W S Page 7 r
I Reactor Restart Process l
RECOMMENDATIONS 1
To provide effective internal controls for MC 0350 restarts, we recommend g
that the Director, NRR:
1.
Establish a definitive process for tracking and documenting the l
resolution of restart issues.
To ensure that timely and adequate information flows between NRC and FEMA, we recommend that the Directors, NRR and AEOD:
2.
Work with FEMA to establish contact points within the agencies for all communications regarding EP issues related to l,
reactor restarts.
I; AGENCY COMMENTS On July 28, 1993, the Deputy Executive Director for Nuclear Reactor l
Regulation, Regional Operations and Research responded to our draft report and agreed with the two recommendations contained therein.
He also g
suggested clarifying language for several sections in the report, and we have 5
made changes where we believed appropriate.
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Appendbc I Reactor Restart Process OBJECTIVES, SCOPE, AND METHODOLOGY We initiated our review to assess NRC's management of the reactor restart process. Our objectives were to (1) determine the effectiveness of the restart h
process, specifically, how NRC identifies, tracks, and resolves restart issues, B
(2) determine how NRC considers EP concerns in the restart process, and (3) examine NRC's proces: for assessing EP at Turkey Point.
We conducted our review from December 1992 through May 1993. We reviewed NRC rules and regulations, and the Memorandum of Understanding I
on EP between NRC and FEMA. We examined restart tracking documents, regular and special inspection reports, Systematic Assessment of Licensee I
Performance reports, diagnostic evaluations, and other documents. We also reviewed Turkey Point Unit 4 lessons-learned reports prepared by NRR and Region II. We visited and interviewed officials at NRC Headquarters, NRC l
Regions I, II, and V, FEMA Headquarters in Washington, D.C., FEMA Region IV (Atlanta), FEMA's Disaster Field Office in Miami, and FP&L officials at the Turkey Point site in southern Florida.
We examined restarts identified by NRC management, as well as restarts I
selected from shutdown data provided by the Office for Analysis and Evaluation of Operational Data. We selected a total of 17 restarts for review.
but focused our attention on those 8 that more closely met the c iinia l
contained in NRC Inspection Manual Chapter 0350.
I Our review was conducted in accordance with generally accepted Government auditing standards.
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Appencfix 11 j
Reactor Restart Process i
RESTART DATA COMMUNICATION FLOWS CNEDff RESTART DATA COMMEDOCATEM MRW FROM leC 70 FEMA DURING AN puramMCYEN NRC PREPAREDNESS hM N)
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I SUGGESTED RESTART DATA COMMUNICATION HAW 8 DURING AN EMERGENCY RESPONSE NRC ITLEFAREDNISS Restan Data IT.hu PREFAREDNESS I
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'HW improved internal NRC communauons may prende couracahon to IIMA's prrporedness organizacon. addanonal
- ~~uorm from both NRC orgn=== will prende furttwr namrance that EMA (p.;;,--s receres mry infonnauon.
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i Appendbc ill Reactor Restart Process U.S. NRC ORGANIZATIONAL CHART NkC Commissioners l
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Apperdbc IV Reactor Restart Process AGENCY COMMENTS ON DRAFT REPORT
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Julygig329 P2:34 MEMORANDUM FOR:
David C. Williams Inspector General Office of the Inspector General FROM:
James H. Sniezek Deputy Executive Director I
for Nuclear Reactor Regulation, Regional Operations and Research
SUBJECT:
REVIEW OF NRC'S REACTOR RESTART PAOCESS I
I am resoonding to your memorancum of June 29, 1993, in which you transmitted the craft audit report on the reactor restart program. I am pleased to note I
your finding that the revised guidance establishes a systematic approach and strengthens the reactor restart process. With respect to your specific reco=endations for additional actions to further improve the process, I suD::.11 the following responses:
oecommendatien !
I Establish a definitive process for tracking and documenting the resolution of restart issues.
Cesrom e Agree. NRR will revise Inscettien Manual Chapter 0350, " Staff Guidelines for Restart Acoroval.' to clarify how the Restart Action Plan is to be used to track status and to provice additional guidance for occumenting the resolution of restart issues. Comoletion date: September 30, 1993.
Feco-encation 2 I
Work with FEMA to establish contact points within the agencies for all comunications regarding emergency preparedness (EP) issues related to reactor restarts.
Pesrom e Agree. On June 17. 1993, the Executive Director for Operatiens (EDO) formally designated NRR's Director. Civision of Radiation Safety and Safeguards (DRSS).
I as co-cnair of the NRC/ FEMA Steering Committee on Emergency Preparedness, which is responsible for ensuring that the provisions of the NRC/ FEMA Memoranaum of Understanding (MOU) on Radiological Emergency Planning anc Precareoness (hereafter referred to as MOU on EP) are properly carriec out.
By letter of June 22. 1993. the Director, DRSS, informed FEMA's co-chair (the Assistant Associate Director. Office of Technological Hazards) of his y{
appointment and ioentifiec the other NRC members of the Steering Committee.
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I Appendix IV Reactor Restart Process David C. Williams Also on June 17, 1993, the EDO signed a revision to the MOU on EP containing, among other things, an amendment, approved by the Comission on May 27, 1993, that specifically addresses comunications between the NRC and FEMA regarding EP issues related to reactor restarts during recovery from disasters. The 3
revised MOU on EP will become effective when it is countersigned by FEMA's E
Associate Director.
Additionally, the Director, AE00, will ensure that NRC and FEMA preparedness E
organizations will be added to the standard address list for Status 5umaries, 5
the NRC's emergency status reports.
With respect to the report itself, I find the report to be concise and to provide an accurate sum:tary. The coments provided below would, in my opinion, clarify the circumstances and avert potential misinterpretations surrounding the restart process.
Page 1, 3rd paragraph, Page 6, Communication Channels, 1st and 2nd paragraph; page 7, 1st line; page 8, Conclusions, 2nd paragraph; Appendix 1, page 1, 2nd paragraph
" Memorandum of Understanding" should be revised to state, M00 on EP" in order to distinouish it from another MOU between NRC and FEMA on Incident Response (dated October 22,1980).
Page 2, last paragraph, should be revised to read:
On August 24. 1992, Hurricane Andrew struck southern Florida.
In accorcance with its emergency planning procedure, 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> prior to the arrival of the hurricane, FP&L brought the Turkey Point Units 3 and 4 to a shutdown condition. As a result of the hurricane, the site sustainea.
Page 4, 151 paragraph I,
The paragraph does not recognize the October 22, 1980 NRC/ FEMA MOU on incident Response. We suggest the following paragraph.
In 1985. NRC and FEMA signed an MOU on EP to delineate the roles and l
responsibilities of the two agencies in the evaluation of State, e
local and licensee prepareoness. A separate MOU on Incident l
Response dated October 22, 1980, deals with NRC/ FEMA cooperation ana a
l respons1bilities in response to an actual or potential radiological gi emergtncy. The agencies are currently revising the MOU on EP" to i
clarify their roles anc responsibilities, and...
Page 7, 1st paragraph, line 6 should be revised to read:
i On C:tober 1. 1992. following discussions between FP&L, FEMA, and the NRC. even though FEMA had not withdrawn its approval for offsite EP, j
FP&L brought Unit 4 to cold shutdown pending FEMA's further j
consideration of the status of EP.
olG/9M49 rage 2 of 3 i
Appendix IV Reactor Restart Process David C. Williams Page 7, 3rd paragraph, 4th line AEOD is the NRC organization that maintains the NRC's response capability; however, the NRC response organization itself is composed of a mix of NRC personnel from various offices. In the Turkey Point case, the Base Team (in the region) was leading the NRC response for the agency. Thus, the sentence should read:
"NRC's response organization also.. "
Appendix II, Suggested Restart Data Communication Flow Please note that the suggested communication diagram can be imolemented only when the NRC is in an emergency response mode and status summaries are being issued. It should also be recognized that the status summaries reflect the emergency situation and the NRC response activities as known at the time of issue and will not routinely contain plant restart information.
psyxiph Ja.es H. Sniezek
.D uty Executive Director i
for Nuclear Reactor Regulation, Regional Operations and Researcn olo/93Am
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Appendix V Reactor Restart Process MAJOR CONTRIBUTORS TO THIS REPORT
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Anthony Lipuma, Team Leader Lee Higgins, Management Analyst
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REMARKS PLEASE PLACE COPY OF THE REPORT IN THE PDR ROOM.
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