ML20082E239
| ML20082E239 | |
| Person / Time | |
|---|---|
| Site: | Hope Creek  |
| Issue date: | 04/03/1995 |
| From: | Hagan J VIRGINIA POWER (VIRGINIA ELECTRIC & POWER CO.) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LR-N95034, NUDOCS 9504110156 | |
| Download: ML20082E239 (9) | |
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Pubhc Sennce Doctre and Gas Cornpany Joseph J. Hagan Public Servce Dectric and Gas Company P.o. Box 236, Hancocks Bridge, NJ 08038 609-339-1200 APR 031995 m.,,..,~.o,,._,
LR-N95034 United States Nuclear Regulatory Commission Document Control Desk j
Washington, DC 20555 INADEQUATE CONTROL ROOM STAFFING CLOSEOUT l
I HOPE CREEK DOCKET NO. 50-354 On February 3, 1995, representatives of Public Service Electric l
and Gas (PSE&G) met with NRC Region I personnel to discuss the investigation into an incident involving inadequate Control Roon staffing at Hope Creek Generating Station and the remediation plan for the individuals that were involved in the incident.
During this meeting, the NRC requested that PSE&G provide a written update of the incident and the associated investigations.
i This update is provided as the following attachments to this letter; Results of Follow-up Evaluations Discipline /Remediation Update There has been a change to some previous commitments relative to the remediation plan. These changes are included in Attachment 2.
Please do not hesitate to contact us if you have any questions regarding this submittal.
Sincere y,
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110065
( qi 9504110156 950403 DR ADOCK 05000354 PDR
APR 081995 -
Doc'unent Control Desk 2
LR-N95034 C
Mr..T. T. Martin, Administrator'- Region I U. S. Nuclear Regulatory Commission 475 Allendale Road King of Prussia, PA'19406
-Willian F. Kane, Deputy Administrator - Region I i
U. S. Nuclear Regulatory Commission 475 Allendale Road King of Prussia, PA 19406-1413-Mr. D. Moran, Licensing Project Manager - Hope Creek U. S. Nuclear Regulatory Commission One White. Flint North 11555 Rockville Pike l
Rockville, MD 20852 Mr. R. Summers (SO9)
USNRC Senior Resident Inspector i
Mr. K. Tosch, Manager, IV
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NJ Department of Environmental Quality Bureau of Nuclear Engineering CN 415 Trenton, NJ 08625
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l ATTACFMENT 1 RESULTS OF FOLLOW-UP RVALUATIONS BACKGROUND The initial investigation report that was prepared received a limited, inadequate management review prior to being transmitted to the NRC._
This inadequate review resulted in the failure of PSEEG management to. fully understand and
" test" the preliminary conclusions of the report.
Subsequent to the 10/18/94 meeting to discuss the report, PSE&G determined that there were differing opinions concerning the conclusions reached during the initial investigation.
As a result, further evaluations were conducted to gain a better understanding of this incident.
A discussion of the follow-up evaluations and the results of these evaluations is provided below.
PROCESS FOR FOLLOW-UP REVIEWS The individuals involved in the incident reviewed the report and identified potential discrepancies.
Several discussions were held with the investigators to determine the basis of the conclusions /significant findings in the report.
The Operations Manager and the General Manager conducted interviews and fact-findings to gain a better understanding of the incident.
PSE&G management conducted an assessment of the identified discrepancies.
The Vice President - Nuclear Engineering and the Vice President - Nuclear Operations conducted interviews with the i
three individuals who were SRO's at the time.
One of the purposes of this interview was to determine if the individuals knew, in 1992, that an incident report was required to be initiated.
4 As a result of the above evaluations, PSE&G management was presented with apparent inconsistencies to the initial investigation report.
These apparent inconsistencies were investigated and resolved.
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j ATTACHMENT 1 i
RESULTS OF FOLLOW-UP EVALUATIONS t
RESULTS OF EVALUATION PSE&G. management realizes that all of the facts relative to June 1992 cannot be completely reconstructed because of the elapsed time and the varied investigations.
However, in the absence of conclusive evidence to the contrary, the following is believed to-be true:
All four individuals realized that the administrative section of Technical Specifications had not been complied with.
The SRO's discussed whether an-incident. report was required I
and concurred with the decision that it was not mandated by administrative procedure.
This decision was made without
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consulting the administrative procedure.
Statements in the report that individuals knew, in 1992, that an incident report was required were conclusions reached indirectly through the interview process.
The interviewees'did not understand that they were being asked i
"Did you know, in June of 1992, that an incident report was required?".
PSE&G management believes that some confusion i
existed on the part of the SRO's when answering investigator questions as to whether they were answering based on their l
1992 knowledge or their current knowledge of incident report 1
requirements.
While the administrative procedure was not explicit for requiring an incident report for non-compliance with the administrative section of Technical Specifications, the SRO's exhibited poor judgment in determining this event did not." warrant management attention."
The SRO's did not
' deliberately disregard station procedures.
t The use of the word collaborate in the report was not
.l intended to mean that there was a conspiracy to cover up.
i It was intended to mean only that the three SRO's had conferred with each other sufficiently to understand that none of them was going to prepare an incident report.
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The SNSS called the QA Engineer to determine what he had observed, not to determine if the QA Engineer was going to write up the incident.
The QA Engineer discussed the facts of the incident with the SNSS, but they did not specifically l
discuss if an incident report should be or would be written.
The SRO's should have known that an incident report was required, and that it was reportable under 10CFR50.73.
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4 ATTACKKENT 1 RESULT 8 OF FOLLOW-UP BVALUATIONS The QA Engineer exhibited poor judgment'in not following up on the initial incident to ensure that un incident report had been issued.
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~The four individuals did not conspire to violate administrative procedures.
The QA Engineer exhibited poor judgment in not ensuring that an incident report was prepared following his discovery that the original incident was not properly documented.
Based on their employment history and demonstrated behavior, PSE&G management confidence in the ethics, honesty, and integrity of the four individuals was confirmed during the investigation.
The remediation was based on the results of the initial investigation.
This incident was representative of a gen 6ric operator training weakness at both Salem and Hope Creek.
SUMMARY
OF SIGNIFICANT FINDINGS The initial investigation resulted in five significant findings.
These findings and the PSE&G position based on the evaluations-are listed below:
1.
The SRO's collaborated not to disclose a known violation of Technical Specifications by failing to-prepare an incident report after determining that'an SRO had been absent from the Hope Creek Control Room.
The investigator has clarified the use of the word
" collaborate."
It was intended to mean only that the three 9RO's had conferred with each other sufficiently to understand that none of them was going to prepare an incident report.
PSE&G concurs that the three SRO's cont;rred sufficiently to understand that none of them was going to prepare an incident report.
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ATTACHMENT 1.
RESULTS OF FOLLOW-UP RYALUATIONS l
s Although the SRO's recognized that the administrative section of the Technical Specifications had not been complied with, they did not equate this with an event that required notification in accordance with the Code of Federal Regulations or the Technical Specifications.
The SRO's'were
. familiar with the reporting requirements of 10CFR50.72 and i
evaluated the incident against that requirement.
The SRO's_
did not consider reportability under 10CFR50.73.
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2.
The SRO's deliberately disregarded Station procedures.
The SRO's did not deliberately disregard Station procedures.
i They relied on their memory and made a poor decision, which resulted in noncompliance with the intent of station administrative procedure on initiating incident reports.
The administrative procedure was poorly worded and allowed for the wrong interpretation by the SRO.
3.
The QA' Engineer compromised independent QA oversight by participating in the collaboration not to report the bsence of an SRO from the Hope Creek Control Room, failing to l
report the incident himself when operations did not do so, and failing to inform his supervisor adequately of the i
incident.
The QA Engineer did not confer with the SRO's as to whether an incident report would be initiated.
When the QA Engineer agreed to let Operations handle it, he assumed that included initiating an incident report.
Operations assumed that it~
q meant they could decide if an incident report was required.
PSE&G concurs that the QA Engineer did not adequately inform his supervisor concerning this incident.
4.
Command and control turnover procei're should be improved by increasing formality or making oth # ghysical changes to prevent recurrence.
PSEEG concurs with this finding.
5.
Management should consider the need to clarify / reiterate the reporting of off-normal events per NAP-6.
PSESG concurs with this finding.
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'S ATTACRMENT 1 RESULTS OF FOLLOW-UP RVALUATIONS i
CORRECTIVE _ ACTIONS Command and control turnover process expectations have been
' reinforced.
A mechanical restraint on the SRO's identification photo badge is being utilized as an additional barrier to prevent inadvertent recurrence.
Management's expectations'for initiating incident reports have been clarified and communicated both to the personnel involved in this incident and other. applicable NBU personnel.
The four individuals involved in this incident have been disciplined and remediated.
Training has been developed and/or enhanced.
Process improvements to investigation process are being made to ensure standardized approach.
The QA Engineer understands and accepts the responsibility to report and follow-up on issues.
QA Engineers performance plans will include expectations for following up on issues.
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ATTACEMENT 2 DISCIPLINE /REMEDIATION UPDATE The four individuals have completed the following remediation plan:
The four individuals each submitted a written response to the investigation report that focused on their role in the incident.
Preparing these responses helped the individuals to gain a better understanding of the issues surrounding this incident.
These responses were prepared on or before 12/7/94.
The four individuals met with SORC, the Licensing Manager, the General Manager - Hope Creek Operations, the Operations Manager, the Manager - Station QA - Hope Creek, and the Nuclear Safety Review Manager.
The purpose of these meetings was for the individuals to gain a broader perspective and deeper level of understanding of their actions and the impact they had.
These meetings were completed on or before 11/2/94.
The four individuals documented the key lessons learned in a Remediation Plan dccument that was completed on or before 11/18/94.
The corrective action recommendations were included in the Remediation Plan document that was completed on or before 11/18/94.
The corrective actions generally focused on the command and control process, training enhancements, and the root causes of this incident.
Presentations to their peers will occur after the remediation is complete.
This is a deviation from our letter of 10/20/94.
The Plent Manager discussed this deviation with the Senior Resident Inspector.
The reason for the deviation is so the individuals would be restored to their normal duties prior to discussing what they learned during the remediation process.
The interviews with senior management to assess if the individuals are ready to return to work were completed on or before 1/23/95.
We have determined that the remediation was successful.
The discipline has been revised as follows:
the two NSS's receivSd an oral reprimand and the SNSS and the QA Engineer received a written reprimand.
The severity of discipline has been revised because it was based on the presumption that the four individuals were involved in a conspiracy.
PSE&G does not believe that a conspiracy was involved.
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ATTACEMENT 2-DISCIPLINE /REMEDIATION UPDATE An observation'and monitoring plan has been put in place to ensure that there are no undesirable after effects as-a result of the remediation process.
The observation and monitoring plan for the-QA Engineer also includes monitoring for timely follow-up, proper decision making, and effective communications.
All four individuals have complied with the revised remediation plan and were returned to their normal duties on 2/6/95.
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