ML20082V188
| ML20082V188 | |
| Person / Time | |
|---|---|
| Site: | Hope Creek  |
| Issue date: | 10/11/1994 |
| From: | Public Service Enterprise Group |
| To: | |
| Shared Package | |
| ML20082V185 | List: |
| References | |
| NUDOCS 9505090010 | |
| Download: ML20082V188 (25) | |
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INVESTIGATION OF AN ALLEGATION OF INADEQUATE CONTROL ROOM STAFFING AT THE HOPE CREEK GENERATING STATION Prepared for PUBLIC SERVICE ELECTRIC AND GAS COMPANY ;
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INVESTIGATION OF AN ALLEGATION OF INADEQUATE CONTROL ROOM STAFFING :
AT TIIE HOPE CREEK GENERATING STATION THE ALLEGATION On August 29,1994, Steven E. Miltenberger, then Vice President - Chief Nuclear Officer, received an " allegation" from a Nuclear Department employee of a violation of the ,
Technical Specifications for the Hope Creek Generating Station. !
Because the employee did not elaborate l Miltenberger asked Robert A. Burricelli, General Manager - Information Systems f and External Affairs, to interview the employee for greater detail.
The employee alleged that, contrary to the requirements of Technical Specification i 6.2.2, which requires a minimum of one Senior Reactor Operator (SRO) and two Reactor ;
Operators (RO) in the Control Room at all times, an SRO had been absent from the Control Room for two or three minutes.1' The allegation further stated that the on-duty Senior Nuclear ,
Shift Supervisor (SNSS) and the two Nuclear Shift Supervisors (NSS) were aware of the [
understaffing and collaborated on not filing an Incident Report as required for a violation of f t
i l' NRC regulations at 10 C.F.R. f 50.54(m)(1)(iii) provide in part that when the unit is in ;
an operational mode other than cold shutdown or refueling, "each licensee shall have a person holding a senior operator license . . in the control room at all times."
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REDACTED VERSION Technical Specifications.
CONDUCT OF TIIE INVESTIGATION After Miltenberger referred the allegations to Burricelli, Burricelli assigned Roy H. Earlman, PSE&G Investigator, and Barbara J. Bronson, Human Resources Client Consultant - Hope Creek, td conduct an investigation. Burricelli assumed responsibility for the investigation under the terms of the Investigations Protocol Burricelli determined that there was no need to appoint a special task force to conduct the investigation, or to develop a special Charter, inasmuch as the underlying allegations were not complex and the issues were straightforward. Eariman and Bronson conducted preliminary fact-finding interviews. '
In the second phase of reviewing preliminary findings, conducting follow-up interviews and drafting the Report of Investigation, Burricelli asked Robert M. Rader of Winston l
& Strawn, PSE&G's outside legal counsel, to assist in the investigation. As a result, thirteen ;
individuals were interviewed. Each of the initialinterviews was conducted in person, while t
some follow-up interviews were conducted by telephone.
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Two other Nuclear Control Operators (NCO), "H" and "I" and another QA engineer, "J" , were interviewed, but had no knowledge of the incident -
or other relevant information. !
INVESTIGATIVE FINDINGS The investigation has confirmed the basic allegation. On June 3,1992, no SRO was present in the Control Room at Hope Creek from 1:38:45 p.m. through 1:41:41, a total of ,
two minutes and 56 seconds. The complement in the Control Room during that shift included 4
REDACTED VERSION SNSS , the SNSS; NSSI ,NSS; NCOI , NCO and NCO2 , NCO.
NSS2 , another NSS, was assigned to the Work Control Room, which is located adjacent to the Control Room, during this shift. Entrance into and exit from the Control Room by the operators have been determined from key card data. The operators have been able to recall their whereabouts outside the Control Room. ;
Nature of thi violation. SNSS left the Control room at 1:01 p.m. to attend a staff meeting in the office of the Operations Manager, which SNSS described as a roll-down :
from the General Manager's staff meeting. At that point, he tur~d " command and control" )
over to NSSI . NSSI wanted to check the status of work by Maintenance on chillers located above the Control Room. He called NSS2 in the Work Control Room to relieve him. Both NSSI and NSS2 agree that NSS1 asked NSS2 to enter the Control Room for the express purpose of relieving him to check out work on the chillers. After NSS2 entered the Control Room, he and NSSI spoke briefly, though neither can remember the particulars.
A few minutes later, NSSI walked behind the instrument console to pick up his hard hat. NSSI believes he said something to the effect of "I'm leaving," but ,
cannot recall his exact words. NSS2 recalls NSSI walking around the console to pick up his hard hat as he was getting ready to leave, but does not recall hearing NSSI saying ,
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anything to signify a tumover of command and control. NSS2 did not see NSS1 exit the m
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REDACTED VERSION Control Room.T NSSI left the Control Room at 1:37:44 p.m. NSSI stated that he did not know how the communication breakdown with NSS2 had occurred. He assumed that .
NSS2 knew he was leaving. Unaware that NSSI i:wd left the Control Room, NSS2 exited the Control Room at 1:38:45 p.m. NSS2 cannot remember why he left, but he returned to the Work Control Room.
QA engineer QAl had entered the Control Room at 1:36:41 p.m., just as NSSI was leaving, and while NSS2 was still present in the Control Room. Recollections vary a bit on how it was discovered that there was no SRO in the Control Room after NSS2 left.
NCO NCO2 believes that 0.11 and he had simultaneously recognized fat there w.3s no SRO present. NCO2 says that QA1 asked him, "Where's the SRO?" just as NCO2 had the same thought. NCOI , the other NCO, says that he saw QA1 in the NSS of6ce overlooking the console and became curious because he didn't see QAl speaking with anyone. This made him wonder, "Where was NSS2?" NCOI says that he walked back to the NSS of6ce, saw NSS2 was not there, and asked NCO2 if he knew NSS2's whereabouts.
Both NCO2 and NCOI claimed to have paged NSS2 or called him at the Work Control Of6ce, requesting him to return to the Control Room immediately because no SRO was l' The Control Room has three doors -- one door located at the rear behind the console, another door located just outside the adjacent Work Control Room, and a 'hird doorjust outside the SNSS's office. Although NSS1 thought he exited the rear door (psnaps explaining why NSs2 had not seen him leave), he actually exited the door by the SNSS's office. A diagram of the Control Room is attached.
REDACTED VERSION present. NSS2 recalls that he was paged by NCOI. NSS2 re-entered the Control Room at 1:41:41 p.m. Inasmuch as NSS2 had left the Control Room at 1:38:45, there had been no SRO present for the interim 2 minutes and 56 seconds. QAl exited at 1:42:01 p.m.
Meanwhile, NSSI had completed his check on the chillers and returned to the Control Room at 1:42:29. The NCO's were uncertain, but it appears that NSS1 ,
unlike NSS2. simply returhed on his own. When SNSS returned at 2:03 p.m., NSS2, NSSI and NCOI filled him in on the SRO absence. NCOI describes SNSS 's reaction to the incident as " unhappy" and upet that so simple a mistake had been made, but did not perceive any strong reaction from SNSS to the news of the absent SRO. NCOI recalls that day as unusually " busy." Apparently, one Control Room chiller was inoperable, and the other chiller was under repair. Operations wanted to avoid initiating a 12-hour Limited Condition of Operation (LCO) for tne remaining chiller, which explains why NSSI went to check on work there. NCOI recalls that there were a variety of other maintenance activities in progress at that time Accounts vary on what the two NSS's told SNSS . NSSI says, "We expressed concern" about the SRO absence, and asked SNSS , "Should we repon this?" NSS2 was even more specific. He recalls asking SNSS , "Do you want me to prepare an IR7" or words to that effect. NCOI , on the other hand, recalls no discussion of whether the incident should be reported. He assumed that an Incident Report had been prepared because of the l
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REDACTED VERSION Technical Specification violation. Nonetheless, he cannot recall any discussion as to how the iricident would be handled.
SNSS recalls things differently. He said tnat when he returned from the staff meeting, NSSI " looked ashen " NSSI told him, "We have to talk about what happened." SNSS took NSSI and NSS2 to his of6ce inside the Control Room, where NSSI explained how h'e had wanted to check the status of the chillers, asked NSS2 to take over in his atcence, picked up his hard hat, and left the Control Room, apparently failing to communicate to NSS2 that he was leaving. SNSS does not recall any discussion of whether an j incident Report should be prepared. Contrary to NSS2, SNSS says that neither NSS2 nor NSSI volunteered to prepare an Incident Report. SNSS considered writing an Incident Report, but recalls thinking, "What's the big deal?" He felt that NSSI and NSS2 "were already paying the price" as shown by their extreme anxiety over the incident, and that reporting the matter would have no bene 6t. He told NSSI and NSS2, "You guys have punished yourselves enough over this and won't do it again" or words to that effect. Nonetheless, SNSS clearly understood that plant Technical Specifications had been violated. He acknowledges that he mentally debated what to do and that it was not a decision he made lightly.
According to NSS2, SNSS said that the event was not that significant. NSS2 did not remember a comment by SNSS that the two NSS's had been " punished enough." Like SNSS . NSS2 was well aware of the Technical Specification requiring an SRO in the Control Room at all times, but he asserts that he did not know at the time whether that meant an Incident I
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Repon was automatically required. From his perspective, NAP-6 has not been interpreted consistently, and does. not require an Incident Repon for every violation of a Technical ,
Specification. According to NSS2, the basis for discussing whether an Incident Report was necessary was whether the incident was significant enough, not whether a Technical Specification had been violated.
SNSS , NSS2 and NSSI each acknowledge individual responsibility for having failed to prepare an Incident Report, which would have notified "A" of the incident. At the same time. each points out that the others must share the blame inasmuch as each of them had an independent obligation to report the incident. SNSS freely admits that not reporting the incident was " wrong," and acknowledges that it was " ultimately my responsibility" to prepare an Incident Repon. Although he does not blame NSS2 or NSSI for his error, he points out that "others could have pushed me" to do the right thing if they wanted. According to SNSS , NSS2 and NSSI seemed " relieved" by his decision to handle the matter by simply talking with both of them, and did not question his decision not ,
to file an Incident Repon at any time during this conversation. NSS2 admitted as much; he says ,
that he felt " bad" that he " dumped" the problem on SNSS by asking him what he should do.
NSSI said that SNSS , NSS2 and he were "on the fence" about reporting the incident, but :
that all three were " comfortable" with the decision not to do so. i SNSS knew that plant Technical Specifications have been violated, and ;
acknowledged that the reason he did not prepare an incident repon was to keep NSS2 and A
I REDACTED VERSION NSSI out of trouble. SNSS had not considered whether a Licensee Event Report (LER) would have resulted from the Incident Report because LER's are prepared by the Technical Department as a 30-day report. SNSS says that this does not involve "on-dutyjudgment."I' According to NSSI , he and NSS2 agreed with SNSS not to report the incident. He said that they concluded that the one or two minute lapse was not significant and had been corrected immediately. On the other hand, he was aware that the Technical Specification had been violated. Although it was not mentioned as such, the Technical Specification was, according to NSSI , "the reason we were discussing" the absence of the SRO from the Control Room. NSSI puts a bit more emphasis upon the ultimate responsibility of SNSS as the SNSS to "make the call" on preparing an Incident Report, although NSSI stated several times that he was "not absolving myself" of responsibility.
He acknowledges that he had an opportunity to prepare an Incident Report and was relieved by the decision to let things rest, but continued to question himself whether the right decision had been made.
QAl 's involvement. Another consideration among the three SRO's was that QA Engineer QAl was present in the Control doom when the NCO and he realized that an SRO was missing. QAl 's responsibilities include oversight of the Operations function.
Apparently pursuing routine business, he entered the Control Room at 1:36:41 p.m. He exited 2'
As discussed below, however, an Incident Report is required for any event requiring notification to the NRC, and NRC regulations explicitly require a licensee to report any violation of plant Technical Specifications by an LER. Therefore, SNSS 's reasoning is faulty.
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REDACTED VERSION l at 1:40:30 p.m., and then retumed thirteen seconds later at 1:40:43 p.m. These data support his recollection that, upon leaving the Control Room initially, he noticed from behind the glass there was no SRO in the Control Room. QAl thinks that the NCO's saw a quizzical expression on his face and picked up on the problem. Apparently, QAl immediately re-entered the Control '
Room and asked one or both of the NCO's about the missing SRO. According to QAl , one of the NCO's advised him that he had noticed the same thing and was in the process of getting an SRO back into the Control Room. QA1 recalls leaving the Control Room before NSS2 re-entered, but the card key data establish that QAl left at 1:42:01 p.m., shortly after NSS2 had returned at 1:41:41. Apparently, QAl had no conversation with NSS2 or the NCO's at that l point as to how the incident should be handled.
During his discussion with NSS2 and NSS1 , SNSS recalls that NSSI i
told him, "You know. QAl was in here." The implication to SNSS was clear: to decide how to handle the situation, he had to know how QAl would react. Therefore, SNSS called QAl from his office to ask him, "What's your read on this?" He says that QAl told him something to the effect that "I had to notify my manager, but we (or I) decided to leave it
[how to handle the incident] up to you," meaning QAl was leaving i: up to SNSS whether i to prepare an incident Report.
NSS2 recalls the same telephone conversation, and says that he heard SNSS admitting that a mistake had been made and that "we'd take care of it." NSS2 did not have the i
overall impression that SNES was looking for guidance on whether the incident should be j 1
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reported. NSSI , who was also nearby and "in and out" of the SNSS office likewise heard SNSS admitting "we made a mistake," and telling QAl that "we would handle it." Neither NSS2 nor NSSI specifically heard SNSS discuss preparation of an Incident Report with QAl.
Whether the conversation between QAl and SNSS took place in SNSS 's office or over the telephone, their accounts vary from each other. According to QA1, he returned to his office and spoke face-to-face with his supervisor, QA2 . QAl says i
that he told QA2 what he had observed, and that he was in the process of contacting Operations. QAl recalls that, at that point, he was paged by SNSS and returned to the Control Room, where he spoke to SNSS in the SNSS office with NSS2 and NSSI present. His account is supported by card key data showing that QAl re-entered the Control l Room at 2:16 p.m. and exited at 2:25 p.m. SNSS, NSSI and NSS2 recall, however, that i SNSS spoke with QAl by phone. They do not remember QAl returning to the Contrei )
Room again that day.
According to QAl , SNSS told him that he would handle the situation himself.
QAl says that he did not challenge SNSS 's decision; he simply accepted it and left. QA1 asserts that he overheard SNSS telling NSSI and NSS2 that he did not want to tell "A" what had happened and that he would take care of it. QA1 maintains that "I don't want "A" to find out" is almost a direct quote from SNSS stated in the presence of
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SNSS does not recall QA1 returning to the Control Room that day.
Notwithstanding the key card information, SNSS claims that "I honestly don't remember him being there" at that time. In any event, he vehemently denies telling anyone that "we don't have to bother "A" with this information."d' SNSS disagrees with QAl 's account that he told QAl that he would " handle it." Rather, SNSS maintains that he discussed the' details with i QAl , and that QAl left it to his discretion whether to write an Incident Report. SNSS
, says that he accepted QAl 's decision leaving preparation of an Incident Report up to him, and 'I
, decided after further discussion'with NSS2 and NSSI not to write an Incident Report. j SNSS does not claim that QAl agreed with a decision not to file an Incident Report, but !
points out that QAl . understood the requirement for filing an Incident Report and did not !
challenge SNSS 's decision not to prepare one. Although there was no " formal buy-off" into j that decision, SNSS felt that QAl 's failure to object gave him a " level of confidence" sufficient to take the action he did. ;
Because of the difference in opinion as to whether the conversation with QAl l i
was in person or by phone, it is unclear how much NSS2 or NSSI overheard. NSS2 says j that he did not see QAl again that day after being paged by the NCO to return to the Control l i
Room. NSSI says he did not hear all of the telephone conversation because he was "in l
and out" of the SNSS's office, but heard no comment that SNSS did not want to inform "A" (
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During the interview, SNSS appeared genuinely upset by this suggestion. He said that, j while recognizing that the interviewer was simply asking a question, "you really got my ;
goat with tha' " '
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- about the incident. NSS2 likewise does not recall seeing QA1 for the remainder of the day, i but adds that SNSS could have met with QAl without his lotowledge because he was in the Work Control Room. NSS2 said that SNSS did not mention either "A" or "B" , then l
the , , during their discussion of the incident.
NSSI likewise denies that there was any discussion about not informing "A" of this event. .
t QA2 's involvement. A related aspect of this incident is what happened j between QAl and QA2 , his supervisor. QA1 maintains that he originally reported the absent SRO to QA2 , including SNSS 's alleged statement that "I don't want "A" to find l out" about the absent SRO. QAl says that his supervisor nevertheless told him to "let it go." ;
The exact sequence of conversations between QA1 and the operators and between QA1 and i
QA2 is unclear, but QAl claims that he came away from his discussion with QA2 with l
the impression that it was all right to let SNSS handle things on his own without writing an !
Incident Report or otherwise informing "A" .
QA2 adamantly denies any such conversation with QA1 regarding the absent !
SRO. He claims to have an excellent memory and does not recall either the incident or anyone l mentioning it to him. QA2 vigorously denies being aware of the incident or speaking with l
QAl about the incident. He states that, if it had been mentioned to him, he would have j immediately gone to "A" or "B" to advise him of the Technical Specification violation. QA2 adds that, if !
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REDACTED VERSION informed, he would have looked for an Incident Report to have been prepared. Further, he would have expected QAl to prepare a Surveillance Report to document what he had seen and what action he had taken. QA2 said he is unaware of any instance in which Operations staff had ever said there was "no need to write up a formal report" on an event that should have been reported. He acknowledges that, assuming QAl did speak with him, QA " blew it," and
, he w'ould have to take personal responsibility.
QA1 says that he advised QA2 of the understaffingincident outside QA2 's office by his secretary's desk. Therefore, the investigation included the interview of two QA colleagues who might have known of QA1 's activities that day as well as QA2 's secretary.
"C" was a QA engineer at Hope Creek in June 1992. He recalled QAl returning to the QA office and remarking " nonchalantly" that he had been in the Control Room and noticed that there was no NSS there. To the best of his recollection, "C" recalls QAl saying, "I went and took care of an event with Ops, but think QA2 should be aware." If "C" 's recollection is correct, it negates QAl 's assertion that he checked with QA2 before agreeing with SNSS to let SNSS handle the incident on his own. Also, it would lend credence to the explanation that QAl only vaguely mentioned a problem with Operations to QA2 as an afterthought without sufficient detail to expect QA2 to take action on his own.
In any event, "C" never saw QAl actually speak with QA2 about the )
incident. He perceived the matter as being " closed" because he assumed QAl had already taken appropriate action. He did not know what QAl meant by "taking care" of the incident, 1
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REDACTED VERSION but assumed from his tone of voice that he had done whatever was necessary. "C" said that he had never heard of any incident where Operations staff asked QA nct to write up a reportable incident; such a statement would reflect poorly on the integrity of both QA and Operations.
"D" , a QA engineer presently assigned to , sat across from QAl in June,1992 and also car-pooled with QAl . He recalls that QAl informed him at :he time that he had' noticed two supervisors, including NSSI " missing" from the Control Room. QAl told "D" that he had informed a manager in QA and either the Operations Manager or Operations Engineer. According to "D", QAl told him that he had spoken with QA2 , advising him that the Operations Manager (or Operations Engineer) would take care of the incident. "D" did not personally witness any discussion, however, between QAl and QA2 on this subject.1' l' Two others were interviewed to see if they overheard this conversation. "F" was the and QA1 's immediate supervisor in June 1992, but was on a special assignment at that time and unaware of this incident.
"E" , QA2 's secretary at the time, could not recall any conversation between QAl and QA2 about an SRO missing from the Control Room.
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-l Purparation of an Incident Report. There is confusion as to where the principal l l
responsibility lies for initiating an Incident Report if an abnormal event is discovered during the '
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REDACTED VERSION QA/Opeations interface. Everyone agrees that neither organization can default on its independent responsibility to do so, but it is unclear wnich would be expected to assume primary responsibility. QA2 stated that, in 1992, he would have expected Operations to write the incident Report. "If [ Operations) wouldn't write it," QA would. Today, however, QA2 would expect QA to initiate the Incident Report. "C" expressed the view that QA1 , as the identifier of the probleni, should have written the Incident Report. "F" , on the other hand, said the preparation of the Incident Report should be the responsibility of the line organization. In his view, if the line organization refuses to initiate the Incident Report, it raises questions about its professionalism. For their part, the Operators apparently understood that they had primary responsibility for initiating the Incident Report on the absent SRO, but allowed the shared responsibility with QA and QAl 's indifferent rciponse to dull their recognition of what had to be done.
Attitudes about raising safety issues or violations with Operations management.
Uniformly, Operations staff as well as the QA engineers denied any reluctance to " bring the bad news" to management. From the prospective of NCOI , keeoing management informed of pertinent events, good or bad, was routine. NCO2 said that he perceived no reluctance to giving " bad t
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m REDACTED VERSION news" to the Hope Creek managers. He said that has not been the way we do business at Hope
' Creek" since his employment there in 1985.
As noted, SNSS chafed at the suggestion that he was reluctant to bring bad news to " A" . NSSI agreed that there was no reluctance among the operators to bring bad news to their supervisors. In QA, QA2 said that he was unaware of any mentality in Operations that bad news'should be hidden from supervisors. "F" says he sensed no hesitancy among operations personnel to report information to the managers. He pointed out that personnel are aware of their responsibilities as well as their right to do so under NRC regulations.F "C" said that Operations would have "self-identified" violations in 1992 and "still does." He sensed no reluctance to report violations to Operations management. QA2 was of the opinion that "A" , "B" and "K" have all fostered a proper attitude on '
reporting important matters to management. He described "A" 's attitude in particular as encouraging subordinates to bring pertinent information to his attention rather than receiving it from other sources, i.e., "if QA found something, why didn't Operations find it first?"
i F p- added that QAl had previously told him he sensed " hesitation" in one instance of the filing of an Incident Report by Operatio4 s The incident involved personnel error in driving a refueling bridge in December 1993. "F" pointed out that the report was written a bit afterwards only because the shift ended at the time of the event. He told QAl that he saw no basis for him to conclude that the individual was hesitant about writing an Incident Report.
. . . e REDACTED VERSION ANALYSIS The investigative findings led to several conclusions of operational and regulatory ;
significance.
The Senior Reactor Operators deliberately failed to file an Incident Report clearly required by NAP-6. It is undisputed that an SRO was absent from the Hope Creek l
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Control Room for two min' utes and 56 seconds, contrary to NAP-5 (Attachments 3 and 8) and Technical Specification f 6.2.2. SNSS , NSS2 and NSS1 admit that this violation became i i
known to them immediately after its occurrence on June 3,1993; that they recognized the incident as a violation of plant Technical Specifications; that they further recognized the requirement for reporting the violation by preparing an Incident Report;I' and that they nonetheless failed to do so. As discussed below, the operators should have realized that a report to the NRC by way of an LER was required for any violation of Hope Creek Technical Specifications, and should also have known from NAP-6 that any event reportable to the NRC requires preparation of Incident Report.
Moreover, SNSS then checked with QAl , with the knowledge and at least ,
implicit concurrence by NSS2 and NSS1 , to make sure that QA1 did not plan to prepare an Incident Report himself. In this way, SNSS intended to gain at least tacit support for allowing the operators to " handle" the matter among themselves. By their reaction to the I' NSS2 waffled on this point, but as discussed below, the requirement under NAP-6 for ;
preparing an Incident report on a violation of a Technical Specification is clear.
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incident at the time as well as their interview statements, the three operators acknowledged that !
t reporting the incident would have reflected poorly on NSS2 and NSS1 and could have led to disciplinary action against them, such as a letter of reprimand in their files. The inference is therefore unavoidable that the three operators collaborated on June 3,1992 to conceal the incident so as to avoid professional embarrassment and possible disciplinary actio'n.
The requirenients of NAP-6 for preparing an Incident Report apply equally to the i two NCO's. In these circumstances, however, both NCO2 and NCOI observed SNSS ,
NSSI and NSS2 discussing the fact that there was no SRO present in the Contro: Room after NSS2 left. NCOI himself participated to some degree in that discussion. Accordingly, both 9
l NCOI and NCO2 reasonably believed that SNSS had sufficient information to prepare an Incident Report or to direct someone else to do so. Given the responsibility of the SNSS to direct paper flow in the Control Room, it was not unreasonable for NCO2 and NCOI to ;
assume that SNSS was taking care of the Incident Report personally or through one of the NSS's. ,
Turnover of command and control was inadequate. As described by the ;
operators, the procedure for turning over command and control of the Control Room is informal.
Informality led to poor communications between NSS2 and NSSI in making the exchange on June 3,1992. At least from the prac; ice of the operators interviewed, there is no agreed-
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upon or recognized sequence of statements to turn over and accept command and control. It is ;
unclear whether operators even required visual contact with each other in turning over command l
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. . l REDACTED VERSION and control. SNSS saw NSSI 's turnover of command and control to NSS2 as inadequate in this instance. He believes that a quick comment would be all right if the on-duty NSS just needed to go the men's room, but "you've got it" is insufficient. According to NSS1 , the normal procedure for turnover of commanding control is to see that the SNSS or NSS is there, 3 and to yell out that you are leaving.
Up until this' incident, informal exchanges were apparently reliable, though the most recent incident of an absent SRO (as reported by Incident Report 94-162 on September 29, 1994) should cast further doubt on the reliability ofinformal turnover. Operations management needs to assess the mechanics for turning over command and control, perhaps by creating more formality to the exchange or some physical means (design changes, changes in cards or badges) to assure a proper exchange. !
The QA engineer joined in the collaboration among the SRO's and failed to exercise appropriate independent oversight of Operations. It is undisputed that QAl witnessed the absence of an SRO in the Hope Creek Control Room on June 3,1992; that he later discussed the incident with SNSS and agreed to let SNSS " handle" the matter privately with NSS2 and NSS1 ; and that QAl did not personally report the incident by way of an Incident Report or Surveillance Report. Additionally, QA1 asserts that he mentioned the incident to QA2 , his second-level supervisor.
By his own admission, QAl encouraged and supported the collaboration by l SNSS, NSSI and NSS2 not te disclose the incident through normal reporting channels ;
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to senior managers. SNSS was looking for a signal from QA1, who had an opportunity to i
stop ' SNSS from going astray, but QA1 failed to stand firm on what Station procedures clearly required. It is clear from the circumstances that the SRO's would have respected his position if QA1 had stuck to the requirement for preparing an Incident Report. Regardless !
of what actions might have been taken or were taken by the SRO's, QAl had an independent duty as a QA engineer to report the incident himself. Further, he was obliged to file a I Surveillance Report documenting what he had observed per NAP-18 6 5.4.2, which states: "All surveillance activities shall be documented." Finally, by participating in the collaboration, QAl compromised QA's overall effectiveness as an independent oversight organization.
It is unclear whether QAl advised QA2 of the incident. If so, however, he did so only in passing and so vaguely as not to alert his supervisor to the violation he had observed. He certainly did not make it clear to QA2 that he had agreed with the operators to ignore internal reporting requirements for Technical Specification violations. Hence, the j evidence is too weak to support a conclusion that QA2 personally knew-ough to report the incident on his own.
Clarification / reiteration of Incident Report preparation should be considered.
As noted, SNSS thought at the time that missing an SRO for three minutes was net a " big I deal" requiring completion of an Incident Report. NSS2 thought that NAP-6 had been interpreted )
inconsistently and required an Incident Repon only for events with safety significance. The Operators were undoubtedly rationalizing what they really wanted to do anyway, but even if self-
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. serving, their thinking points to a need to clarify or at least reiterate management's expectations i
for reporting off-normal events. ;
NAP-6 states in Section 6.7 that reportable incidents include "[a]bnormal plant !
situations that are not desired to recur," including "any situations that could affect nuclear safety +
or the health and safety of the public . . . and other unplanned events affecting operations, reliability, or personnel saf'ety." Attachment 2 to NAP-6 provides various examples of off- ,
r normal events. Most clearly and significantly, Example One requires personnel to report "[a]ny event requiring notification in accordance with the Code of Federal Regulations . . . . " Under !
10 CFR : 50.73(a)(2)(i)(B), a licensee is required to file an LER to report "[a]ny operation or I condition prohibited by the plant's Technical Specifications." Accordingly, NAP-6 ;
unambiguously requires personnel to prepare an Incident Report on any event requiring !
notification to the NRC by way of an LER, and an LER is required for any violation of plant .
Technical Specifications.
Additionally, there are other provisions in NAP-6, Attachment 2, which should have reinforced the operators' responsibility for reporting the absence of an SRO in the Control Room, for example:
- 2. Events of transients of an operational or administrative nature that warrant management attention, follow-up analysis / investigation, documentation of circumstances surrounding an event, or present a potential precursor to a more serious event.
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- 3. Opera.ional errors that jeopardized, or could have jeopardized, personnel safety.
- 11. Procedural inadequacies that led to, or could have led to, an operational or personnel safety concern.
- 12. Procedural noncompliance which led to, or could have led to, an operational or ' personnel safety concern.
Management must communicate its expectation that incidents like the absent SRO are clearly j
within the spr.:trum of internally reportable incidents per NAP-6.
SUMMARY
OF SIGNIFICANT FINDINGS As a result of the investigativ, the following significant fmdings have been made:
- SNSS , NSS2 and NSSI collaborated not to disclose a known violation of Technical Specifications by failing to prepare an Incident Report r.fter determining that an SRO had been absent from the Hope Creek Control Room.
The SRO's deliberately disregarded Station procedures. The NCO's reasonably believed that an Incident Report was being prepared by others.
- QA1 compromised independent QA oversight by participating in the collaboration not to report the absence of an SRO from the Hope Creek Control Room, failing to report the incident himself when Operations did not do so, and failing to inform his supervisor adequately of the incident.
Command and control turnover procedure should be improved by increasing formality or making other physical changes to prevent a recurrence. ,
Management should consider the need to clarify / reiterate he reporting of off-normal events per NAP-6. .
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