ML20059A811
| ML20059A811 | |
| Person / Time | |
|---|---|
| Site: | Maine Yankee |
| Issue date: | 08/10/1990 |
| From: | Nichols S Maine Yankee |
| To: | Martin T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| References | |
| IEIN-83-28, MN-90-78, SEN-90-232, NUDOCS 9008230237 | |
| Download: ML20059A811 (10) | |
Text
_
. _.. ~
1 J-Ma'inEYankee af vaatt tteciactv 5on vA.NE siNcs +2 EDISON drive
- AUGUSTA. MAINE 04336 * (207) 622-4868 NOTE:
PLEASE SUBSTITUTE THIS LETTER FOR ONE PREVIOUSLY RECEIVED.
THE 1
AlTACHMENT WAS NQT INCLUDED.
August 10, 1990 MN-90-78 SEN-90-232 Region I.
l UNITED STATES NUCLEAR REGULATORY COMMISSION 475 Allendale Road King of Prussia, PA 19406 Attention: Mr. Thoma:: T. Martin, Regional Administrator-
Reference:
(a)
License No. DPR-36 (Docket No. 50-309)
(b)
Emergency Preparedness Exercise and Routine Inspection-Report 88-09, 90-14 (c)
IE Information Notice 83-28' (d)
Executive Sumary, HPES Report 90-013
Subject:
Corrective Actions to Improve Emergency Preparedness Gentlemen:
Maine Yankee's 1990 Emergency Preparedness graded exercise was held on the evening of July 31, 1990.
Overall, Maine Yankee successfully demonstrated the ability to protect the health and safety of the public under the. challenge of a postulated severe accident.
The overall performance of our emergency -response personnel confirm the recent-improvements made in. response center organization and staffing. Several strengths were noted in the areas of TSC 'comand and control, and OSC control of in-plant teams.
Maine. Yankee and staff -observers' also noted
)
weaknesses in three areas for which we have initiated imediate corrective actions.
The weaknesses noted were:
l l
1.
Non-conservative and untimely PAR development 2.
EOF comand and control 3.
Lack of understanding of current plant conditions in the EOF
.l 4-In response to these observations, and as discussed with members of your staff on August '3,1990, Maine Yankee Management has developed a Short-Term Corrective Action Plan to imediately address these observed weaknesses.
0003s
'SEN90232.LTR 9008230237 900810 l
PDR ADOCK 05000309 1
l
)
a PDC
. UNITED STATES NUCLEAR REGULATORY COMISSION MN-90-78 Attention: Mr. Thomas T. Martin Page 2 To address the non-conservative and untimely PAR development in the EOF the following actions.shall be taken:
l.
Remedial training will be given to available Emergency Coordinators, i
Assistant Emergency Coordinators, and Radiological Evaluation Assistants in the use of Maine Yankee's procedures for -developing PARS based on envire,amental,. core and. containment conditions.
These procedures incorporate the guidance provided in IE Notice 83-28. This training will be conducted by August 13, 1990.
Those personnel on vacation-will be trained as soon as. practical after their return.
2.
Utilizing the Maine Yankee Human Performance Evaluation System (HPES), a specific evaluation was conducted to analyze the circumstances associated.
with the initial General Emergency PAR development.
The results were presented to Management on August 8,.1990.
The HPES found:that the PAR procedure, training and TSC/ EOF communication - were all-deficient and-contributed to the outcome. The proposed corrective actions described in-the HPES evaluation have been accepted by management (although the detailed actions to be taken may -vary somewhat from--the HPES) and a schedule is being developed to resolve these items.
The short-term.
corrective actions include:
a.
Conduct additional training on PAR development by August 13, 1990.
l b.
Revise Procedure - 2.50.16, Protective Action Recommendations, to improve PAR development guidance by September 21, 1990.
c.
Improve the flow of ' information~ between the. centers by-routine conferences or other means.
The longer-term corrective actions are = being added to the-Emergency Program Improvement Plan. We will be prepared to discuss these actions at our next meeting with you.
A copy of the HPES executive summary is attached for your information.
To address the. issue of EOF command and control activities, the following actions shall be taken:
1.
A previous. Emergency Coordinator with extensive experience.in EOF operations will be retrained and placed on the Emergency Roster by August 15, 1990.
2.
To demonstrate adequate performance of this Emergency Coordinator, and the EOF team as a whole, an additional Emergency Preparedness Drill will 'be.
conducted by September 21, 1990.
j SEN90232.LTR i -
1 m
e
+--- -.. -. - -.
.as e-.,
c
+-
--+-,-n,--<
vw-
i i
g UNITED STATES NUCLEAR REGULATORY COMMISSION MN-90-78 Atter' ion: Mr. Thomas T. Martin Page 3-l To address the issue of the lack of understanding of_ current plant conditions j_
in the EOF, the following action has been taken:
l.-
The Vice President, Operations, has directed the Plant Manager, by Memorandum, that he is to ensure consistent understanding of current plant i
conditions within the Emergency Response Centers.
1 Additional long-term corrective actions are being developed and will' be tracked by our existing Emergency Preparedness Improvement Plan.
We believe these' actions will improve our ability to respond to accidents and continue to ensure the-health and safety of the public.
If you have any questions, please contact us.
l Very truly yours, s'
b$Abcbk S. E. Nichols Licensing Section Head SEN:SJJ Attachments c:
Mr. Eric J. Leeds Mr. Charles S. Marschall i
L.
Mr. William B. Lazarus Mr. Ronald G. Bellamy l
Mr. Charles G. Amato~
DocumenttCofitFo1 Desk t
4 SEN90232.LTR
--w-
-,r-
.w, c-v+er--,
,,, -.-w+,
-,v
-,e
,ps,,
.... ~
+
1 EUNAN EXECUTIVE SUNNARY HPERFORNANCE ENEANCEMENT-SYSTEM 1.
Nuclear Unitt Maine Yankee 2.
Event Dates Time-2054, Month-July, Day-31,-Year-1990 3.
Report No.:
90-013 4.
Evaluator J. F. Crowder 5.
Event Description During the annual Emergency Exercisek conducted.on 7/31/90, a-protective action-recommendation was made by the Radiological Evaluation Assistant (REA) and the Emergency Coordinator.(EC) which-was untimely and non-conservative.-
This decision was based on simulated events and data as provided by the associated Emergency Exercise scenario.
6.
Human Performance Problems:during Events, j
Descrietion of Inneorocriate Action
&_3epeat?
Consecuences I
1 The REA and the EC incorrectly.
NO An untimely,'under-circumvented guidance given in conservative PAR Attachment'"A"lof PAR Procedure
.was made.
I 2.50.16 and=instead relied on guidance given in Attachment "B" of the same procedure.
7.
Equipment Pailure/ Condition Affecting Ruman Performances L
Descrintion of Ecuinment Problem..
Consecuences Reference 1
l l
This section not applicable.
The. inappropriate action took place during a scenario-driven simulated emergency during which equipment L-failures / conditions are intentionally. introduced to test' human performance.
l HPES.JFC s
m m
E.
s m-re---.
4.%...
-.ans e
8.'
EVENT NARRATIVE (CHRONOLOGICAL DESCRIP TION):
On July 31, Emergency Exercise was conducted and i1990 at approximate i
site emergency centers and escalation of th
..the annual Maine Yankee ncluded activation of all on-through and including the General E mergency classification.e simulated acciden Upon declaration of the General Emer responsibility of the EOF to make a protto the state, b gency at 8:34 p.m., it became the (PAR) information available at the time ective action recommendation ons and environmental Using the Emergency Plan Implementin Radiological Evaluation Assistant and thg Procedure 2.90.16 the appropriate attachments e Emer
(" PAR's'"
guidance to recommendProtective Action Recommendation (Both "A" and "B") gency Coordinator u)s,ed the Attachment "A"provided them theto assist in Zone only s.(EPZ) population. partial evacuation of the Emergency Plann helter portions of the EPZ populatiAttachment "B" provided them the guid more conservative of the two paths on.
ance to less conservative route (e.g. e Instead of taking the (e.g. sheltering).vacuation) they took the The PRR was also untimely in that it(20) minutes after t aration was made.was not made until 8:54 p 9.
Summary of Factors that Influenced H uman Performances Behavioral Analysis - How it Hannened f Radiological Evaluation AssistantThe inappropriate PAR of or the Inaneroeriate Action vs. evacuating based on a preconceived idea that m kiand the Emergency, Coord made by the information, including but not limited tconsensus decisio a
ng PAR's was a concert or information environmental r ng several sources of thyroid doses to the public. projections regarding whol o:
al it is merely incomplete.
e off-What the decision maker then has to dTh o y and him to based on plant data onlytake the PAR decision tha
- ect,
, and comp (are-it to the PAR decision o is of the PAR procedure) that Attachment B leads him to bas d leads more conservative / extensive PAR needs to b e
on environmental data.
To an extent e implemented.
Then, the t
protective ac, tion recommendations is a cocognitive overload was usually made in a noisy mplex pro, cess which isin that making from many different sour,ces.y environment, with information l i bus i
a nput HPES.JFC
l L
f 10.
Summary of Causes:
i Causal Analysis - Why it Hannened R
There were three contributing factors to the inappropriate action.
1.
PROCEDURE I kvas than adequate).
E-Plan Impleser. ting Procedure 2.50.16 " Protective Action Recommendationc" is inadequate in that it does not provide clear direction to the user to select the more conservative PAR, after considering the guidance given in both attachments "A" and "B".
The-procedure also contains other human factor flaws which.are addressed in the next section " Proposed Corrective Actions".
l 2.
TRAINING (Less than adequate)
Most individuals involved in making the incorrect PAR had_ received the incomplete _ impression from their training that making a PAR was a concert of actions / considerations /use of_ multiple charts.
The last critical step (that of.taking-the most conservative PAR) seems to have not been covered or emphasized adequately in training.
l 3.
TRANSMITTAL OF PLANT INFO TO EOF (Less than adequate)
In spite of several " Plant Status Forms" which were. completed by the-TSC and sent to the EOF, all-indicating degrading plant conditions, -
loss of ECCS, and containment readings in excess of 3000_ Rem /hr., the i
Emergency Coordinator did not base his first PAR dec; Jion on core and
~
containment conditions.
He instead relied on-Attachment B,-which presumes a release to the environment and correspondingly significant dose rates.
At the time of the incorrect PAR, most-of the release was still in containment, making Attachment A the better of two sets of guidance that should have been used.
The Emergency coordinator should j
have been more sensitized to degrading core and containment conditions.
There.are several ways to accomplish this in future drills and exercises.
Those methods are' discussed-in the next.section
" Proposed Corrective Actions".
i 11.
Proposed Corrective Actions
]
1.
Procedure i
E.
P. staff should immediately (within 30 days) revise E-Plan Implementing Procedure 2.50.16 " Protective Action Recommendations" to enhance it's value as a guidance document.
The following improvements should be kept.in mind.
a.
Attachment A.needs to be human factored.
As an example, one of'the decision triangles asks "Is containment integrity intact?"
,~'
Considering that the Emergency Coordinator may not'have an operations background, " containment integrity" may need-to he defined.
HPES.JFC t
-~
I
,b.
Attachment D, in it's current form, may provide an-opportunity for confusion, rather than clarity.
Consider retaining some information in the Attachment, but presenting it in a different format, rather than in a third " decision making" table, c.
Insert statements concerning when Attachment A should be used (based solely on known cora and containment conditions) versus when both Attachments A & B should be used (once environmental / radiological data is available).
Insert a final statement stressing that the m211 conservative of the two PAR's reached must be made.
2.
Training E.
P.
staff and the E.
P.
Instructor should immediately schedule (within seven days) a remedial training session and EOF table top exercise for Radiological Evaluation assistants and Emergency coordinators.
The activity should use multiple scenarios to provide players with additional opportunities to formulate Protective Action Recommendations.
The FAR Lesson Plan should be augmented to specifically address lessons learned from the 1990 Annual Emergency Exercise, and should specifically focus on the use of the procedure.
3.
Transmittal of Plant Info to EOF In this report's causal analysis, it was stated that more effectively sensitizing the Emergency Coordinator to plant conditions would have contributed to developing a correct Protective Action Recommendation.
There are several ways to ensure Plant information is adequately received, interpreted, and transmitted by the EOF.
All methods, based on the 7/31/00 exercise, need to be improved and are herein discussed individually.
S.
Plant Status Formg E-Plan Implementing Procedure 2.50.19 " Technical' Support Center" requires the generation of an Attachment B " Plant Status Sheet".
A feature which should be added to Section 3, Current Plant Status of this form is:
L Containment Integrity Intact?
Yes No If No, Explain l
i l
0 HPES.JFC n
l 4
b.
E-Plan Imolementina Procedure 2.50.19 " Technical Suonort Center" The incorrect PAR decision made at the EOF reinforces the observation that better transmittal and interpretation of plant data is needed at the EOF.
One way to do this would be to introduce a new operator-type position to the EOF staff who would assist in interpreting plant conditions.
This, however, might be duplicative of the TSC function.
i l
Instead, I would recommend the following course of action to strengthen the future use and interpretation of plant data by the EOF:
EP staff should revise (in conference with the TSC Coordinator)
Procedure 2.50.19 to restate the two-fold mission of the TSC which is t
l to:
(1)
Monitor plant conditions and advise control room staff regarding plant conditions and/or mitigating plant / core damage and (2)
Advising the EOF when changing plant conditions might affect on-site or off-site radiological conditions.
Although this second TSC objective is mentioned 'in step 4.19 of the TSC procedure, it is not adequately emphasized-up front in the TSC mission statement.
c.
Increase the oractice of inter-center communications
- E.
P. staff should, in future drills, encourage regular conferences between the OSC Coordinator, TSC Coordinator and Emergency Coordinator.
At some utilities, for example, this is done via the use of center coordinator headsets.
Another way to encourage first person conferences is for the Emergency Coordinator or the Recovery Manager to request regular (e.g. every 30 minutes) update meetings.
These meetings provide special opportunities for the various center coordinators to collectively discuss current plant conditions, and plan their continuing mitigating actions.
l 12.
Evaluator Comments t
l Exclanation of receat eroblems, exceotionally cood nerformance noted.
etc.
Personal attitudes of interviewees were consistently positive and included a desire to perform well in their emergency response roles.
As was mentioned in the NRC exit, I believe the 1990 annual exercise was successful in that not only did it exhibit Mai.no Yankee's ability to respond adequately to a plant emergency, but it also allowed some weaknesses in procedures and performance to surface, all of'which will be addressed in a timely manner.
Therefore, the primary purposes of the annual exercise were achieved.
l l
HPES.JFC i
--wr-
1, y
3 MEMORANQUM 1
MAINE YANKEE ATOMIC POWEM COMPANY A
i TO: HPES file DATE: 8/7/90 x
~'
FROM: ~.F. Cro r
FILE:
SUBJECT:
Investigation Activities - 7/31/90 Annual Emergency Exercise INVESTIGATION ACTMTIES RE: Untimely Non-Conservative P.A.R. made during 1
7/31/90 Annual Emergency Exercise I
i 1.
Conducted Interviews.
Interviewed the following individuals: -
Ellen Heath George Pillsbury Bob Nelson Bob Blackmore Doug Whittier Tom Boulette i
Wayne Wcks Harold Siercks l.
Jim Hummer Jeff Temple Jim Hawxhurst l
2.
Reviewed the 1990 Maine Yankee E.P. Exercise Manual / Document y
3.
Reviewed training records of all Radiological Evaluation Assistants, Assistant Emergency Coordinators, and Emergency Coordinatons.' Also reviewed Lesson Plaa #EP-PAR 01 ' Protective Action Recommendations
- i 4
g t.
1 g
1
-e
,..JFC007.mem
- v l..
~
.._..,--.g_..
~ ~ ' '
~ ' * * ' ' " ' ^ '
4-
., c.
HPES Files I
,(
' Page2 l
8/7/90.
~
4.
Reviewed the fcilowing E Plan Implementing Procedures:-
]
2.50.16 " Protective Action Recommendations" 2.50.19 " Technical Support Center"..
2.50.13 " Emergency Operations Facility' l.
5.
Reviewed NRC IE Information Notice 83-28 " Criteria for. Protective Action Recommendations for General Emergencies."
0.
Constructed events and causal factors chart.
7.
Completed HPES forms.
8.
Wrote Executive Summary, Event Narrative, Summary of Factors influencing.
Human Performance, Summary of Causes, Proposed Corrective Actions, and' Evaluator Comments.
t
+
,6 l-1.
4' b
I
- m
'6 1
f JFC007.mem 7
o
- b
.r s "
\\.:;st Gi L ' ii;.%.'t:,D u.;.
.y q;- r
- ---.x a