ML20086T037
| ML20086T037 | |
| Person / Time | |
|---|---|
| Issue date: | 11/30/1991 |
| From: | NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| References | |
| NUREG-1303, NUREG-1303-R01, NUREG-1303-R1, NUDOCS 9201060103 | |
| Download: ML20086T037 (122) | |
Text
__ _ _ _ _ _.
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1-I NOTICE TO ltECIPIENTS OF NUliEG-1303. Iter. I t
4 This revision replaces the entire report and Appendices A and B.
Retain Appendices C, D, and E and all index tabs.
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ABSTRACT
- The incident Investigatior. Manual prescribes guidelines for the conduct of insestigative activities of the U.S. Nuclear Regulatory Commission (NRC) Incident Investigation Teams (llTs). The purpose of this manual is to provide llTs guidance to ensure that NRC invesFgations of significant events are timely, structured, coordinated, and formally administered. The guidelines are intended to assist the investigation rather than limit the initiatives and good judgment or the IIT leader or members. The llT leader and team members should use their experience and those techniques that provide the most confidence in assuring the llT objectives are achieved. These guidelines address IIT activation, conduct of the investigation, conducting interviews, treatment of quarantined equipment, preparation of the team report and followup of staff actions.
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TABLE OF CONTENTS-p.
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A B STR AC T...............................................
iii PREFACE ix P
I GUIDELINE 1: ACTIVATING AN INCIDENT INVESTIGATION TEAM 1-1 1.1 Purpose 1-1
1.2 Background
1-1 1.3 Selection and Scope of Events for IIT Response 1-2 1.4 IIT Discussion and Activation Process 1-4 1.5
- Scope of the Investigation.....................
1-6 1.6 -
Team Selectioa and Composition..........................
1-6 1.7 Participation by Industry Organizations.
17 1.8 Role of the Region During Activation 1-9 1.9
- Upgrading or Downgrading an Investigation 1-10 1.10 Exhibits 1-12 Generic Confirmatory Action Letter......................... 1-12 Generic Order to Show Cause 1-14 Background Information (compiled by the Region) for the IIT B rie fi ng.................................... 1 17 p
Example EDO Menorandum to the Commission 1 18
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NRC Region i Motille Nendestructive Evaluation laboratory..... 1 22 Agreement on Waiver of Compensation, Conflicts of Interests and Releases of Investigation Information for Industry Representatives Participating in Incident Investigation Teams (IITs) 1 26
~ EDO Memorandum on Waiver of Commission Policy on
- Avoidance of Organizational Conflicts of Interest for Industry Participants.............
1.............
Region Action Item Checklist for Activating an lli 1-32 GUIDELINE 2: - CONDUCrlNG AN INCII'ENT INVESTIGATION 2-1 2-1 21 Purpose -............................................
2.2 Background
2.........................................
2.3 IIT Lead Responsibilities 2-1 2.4 Rele of the Region in Support of the Conduct of the Incident Investigation..............................
2-3 2.5 -
Initial Actions by the IIT Leader 3 2.6 Entrance Meeting with the Licensee 2........................
2.7 Plant Tour of Affected Equipment and Systems 2-7 2.8 -
in t e rviewi ng Pe rso nnel _..................................
2-7 2.9 Sequence of Events 2-7 y
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2.10 Quarantined Equipment List (OEL) and Troublechooting Action Plans (TAPS) 28 2.11 IIT Coordination Meetings 28 2.12 Status Reports 2-9 2.13 Collection of Information and Recordkeeping Activities 2-9 2 14 Responding ta Press inquiries 2m 2.15 ldentifying Additional Expertise and Outside Assistance.........
2-10 2.16 Industry Participation in the Investigation 2-10 2.17 Parallel Investigations................................... 2-11 2.18 Referral of Investigation Information to NRC Offices 2-11 2.19 Confidentiality 2 11 2.20 Subpoena Power and Power to Administer Oath and Affirmation 2-12 2.21 Return Site Visit 2-12 2.22 Report Preparation and Presentation 2 12 2.23 Exhibits 2-13 IIT Team Ixader Checklist 2-12 Press Conference Guidance 2-15 Generic Bulletin Board Notice 2-16 Example llT Preliminary Sequence of Events 2-17 Example Preliminary Notification Report 2-20 GUIDELINE 3: CO N D UCTI N G I NTE R VI E WS........................
31 J.1 Purpose 3-1 J.:
Background
31 3.3 Scheduling and Team Attendance.......................
3-1 3.4 Third Party Attendance 3-2 3.5 Interview Guidelines 3-2 3.6 Exhibits 3-5 Guidelines for Review and Availability of Transcripts 3-5 GUIDELINE 4: TREATMENT OF OUARANTINED EQUIPMEN F 4-1 4.1 Purpose 4-1
4.2 Background
4 ~.
4.3 Quarantined Equipment List (OEL)........................
4-2 4.4 Trout leshooting Action Plans...........
4-2 4.5 Exhibits 4-6 Generic Guidelines for Troubleshooting the Probable Causes of Equipment Anomalies 4-6 Exaruple Troubleshooting Action Plan (TAP) 4-8 vi
GUIDEl]NES 5: PREPARATION OF Tile INCIDENT INVESTIGATION TEAM REPORT AND FOLLOWUP STAFF ACI' IONS.......................
5-1 5.1 Purpose 5-1
5.2 Background
51 5.3 Writing and Publishing Guidelines 51 5.4 Report Writing Guidelines 51 5.5 Graphic Guidelines 54 5.6 Publication Forms 55 5.7 Distribution of the Advance Copy..........................
55 5.8 Distribution of the Published NUREG 5-6 5.9 Staff Action Determination and Assignment 5-6 5.10 Staff Action Status la.eporting....
5-6 5.11 Schedule 57 5.12 Exhibits 5-9 Example Report Outline 5-9 IIT Team Leader Checklist 5 10 Example Staff Actions 5-11 APPENDICES A.
NRC Incident Investigation Program, NRC Manual Chapter 0513..........
A-1 B.
Augmented Inspection Team, NRC Inspection Manual Chapter 0325.
B-1 C.
Memo from W J. Dircks to the Commissioners,
Subject:
Incident Investigation Program, SECY-85-208, dated June 30,1985 C-1 D.
Resolution of Industry Comments on the Draft incident Investigation Procedures................................
D-1 E.
Resolution of Regional Workshop Questions Regarding the Incident Investigation Program E-1 vii
~--.- - - - - -.. _ _- -
=[ N PREFACE The objective of the Incident Investigation Program (IIP) is to ensure that operational significant events are investigated in a systematic and technically sound manner to gather
-information pertaining to the probable causes of the events, including any NRC contributh.as or lapses, and to provide appropriate feedback regarding the lessons of experience to the NRC, industry, and public. By focusing on probable causes of operating events and identification of associated corrective actions, the results of the llP process improve nuclear safety by ensuring a complete technical and regulatory understanding of significant events, incident Investigation Teams ensure that significant operational events are investigated in a manner that is timely, objective, systematic and technically sound; that factual information pertaining to the event is documemed; that probable cause(s) are ascertained; and that a complete technical and regulatory understanding of such an event is achieved.
These guidelines were developed and organized by the Office for Analysis and Evaluation of Operational Data (AEOD). In early 1986, a draft of the guidelines were provided to all the owner's groups, the Institute of Nuclear Power Ooerations (INPO), and the Nuclear Safety-Analysis Center (NSAC) for comment. Between January 29.' 1987 and March II,1987, AEOD held five regional workshops to acquaint licensees with the llP. In August 1991, the
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guidelines were revised to clearly define the roles and responsibilitiet of the team leader, L
provide guidance on the followup and closcout of NRC staff actions, address lessoas learned from incident investigations, and incorporate more current illustrative exhibits. The guidelines were also rcvised to incorporate changes to NRC Manual Char'cr 0513 "NkC Incident investigation Program."
These guidelines will foster uniformity, consistency, and thoroughness in llT investigations, Lwhile permitting teams the flexibility to accommodate the diverse nature and scope of future investigations, i
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t GUIDELINE 1: ACTIVATING AN INCIDENT INVESTIGATION TEAM (llT) 1.1 BinKM Guideline 1 provides guidance to NRC management for activating an Inciden: Investigation Team (llT) response to a significant operational event at an NRC-licensed facility, This guideline also provides direction for activating an llT and selecting the number and kinds of expertise required for a timely, thorough, and systematic investigation.
1.2 Erkenstad The scope, objectives, authorities, responsibilities, and basic requirements for the investigation of significant operational events at reactor and non-reactor facilities licensed by the NRC are defined in "NRC Incident Investigation Program," Directive 8.3 (see Appendix A). The Executive Director for Operations (EDO) approves the investigation of a significant operational event by an llT, in part, on the basis of recommendations by NRC headquarters and regional offices concerning the safety significance of the event. The EDO also determines the composition of the llT and approves team members (including composition) based on recommendations by senior NRC managment.
The incident Investigation Program encompasses investigatory responses by an llT and the less formal response by an Augmented Inspection Team (AIT). The major differences between an AIT and an IIT are that:
an llT investigates the mo:.t safety-significant operational events relative to the risk to public heahh and sasty, the IIT leauer and members have not had signincant involvement with licensing a
and inspecuon activities at the affe-ted facility, industry representatives may participate on an llT under the provisions of a e
Memorandum of Agreement between NRC and the Institute of Nuclear Power Operations (INPO).
Events of lesser safety significance whose facts, conditions, circumstances, and probable causes would contribute to the regulatory ar.d technical understanding of a generic safety concern or another important lesson will be assessed by an AIT. NRC Inspection Manual Chapter 0325, " Augmented Inspection Team" is the procedure for activating and conducting an AIT response, maintained by the Office of Nuclear Reactor Regulation (NRR) (see Appendix II).
1-1
1.3 Selection and Scooe of Events for llT RcSp_som5e The recommendation to the EDO for activating an llT should include the identification of the potential safety significance of the event. The threshold for activating an llT is intended to be high and limited to tilose operational events which aw expected to have signi6 cant safety implications. Historically, the events investigated by an IIT have generally involved multiple failures in plant systems, which resulted in system responses that were not part of the design bases, and substantially reduced the safety margins that ensure public health and safety.
SigniGeant operational events that should be considered for an llT response may include one or more of the following characteristics:
(1)
A signi6 cant release of radioactive material to unrestricted areas, or overexposure of personnel to radioactive material.
A significant overexposure or release of radicactive material is an event which s
substantially exceeds the regulatory limits in 10 CFR Part 20, or has the potential for significant radiation or chemical exposure to members of the public. Such events include those which can occur at both reactor and nonreac-tor facilities, and transportation events subject to NRC jurisdiction. In evaluat-ing these events, primary attention should focus on the onsite and offsite personnel health and safety concerns, and consider the offs;te protective actions, and the potential generic aspects of the event. The inadvertent shipment of a radiographic source from Korea to Amersham Co poration, Burlington, Massachusetts, in 1990 is an example of an event of this type. An llT was established because of the natare and potential radiological health consequences and the generic questions the event raised. The UF6 cylinder rupture at the Sequoyah Fuels Facility in 1986 also falls in this category because of the large release of hydrogen fluoride (a reaction product of UF6 and airborne moisture) to the environment, and the involvement of multiple agencies in response to the event. Potential offsite (i.e., public health) radiological consequences are a primary concern and thus, should public health and safety be signincantly impacted or threatened, an llT response would be
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appropriate.
(2)
Plant operation that exceeded, or was outside of the design bases of the facility.
Such events include those where a valid challenge existed yet both trains of a sa cty-related system were lost, or events that were not analyzed in the Updated r
Safety Analysis Report; e.g., the loss of offsite power and failure of onsite power on demand at Vogtle (1990), the total loss of feedwater at Davis-Besse (1985), the precursor anticipated transient without scram (ATWS) at Salem (1983), the failure on demand of the safety injection system at San Onofre (1981), and the Gre at Browns Ferry (1975).
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Manuscript Completed: August 1991 Date Published: Nosember 1991 Omec for Analysis and Esaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 205" J.....,.A 9
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I AIMTRACT The Incident Investigation Manual prescribes guidelines for the conduct of investigative activities of the U.S. Nuclear Regulatory Commission (NRC) Incident Invest:gation Teams (IITs). The purix)se of this manual is to provide llTs guidance to ensure inat NRC investigations of significant events are timely, structured, coordinated, and formally administered. The guidelines are intended to assist the investigation rather than limit the initiatives and goal judgment of the llT leader or members. The llT leader and team members should use their experience and those techniques that provide the most confidence in assuring the llT objectives are achieved. These guidelines address llT activation, conduct of the investigation, conducting interviews, treatment of quarantined equipment, preparation of the team report and fallowup of staff actions.
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TABLE OF CONTENTS
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A B STR A CT................................................
ix
.PREFACF GUIDELINE 1: -ACTIVATING AN INCIDENT INVESTIGATION TEAM 11 1.1 Purpose 11
1.2 Background
1-1 1.3 Selection and Scope of Events for llT Response 12 1.4 IIT Discussion and Activation Process 1-4 1.5 Scope of t he Investigation................................
16 1.6 Team Selection and Composition 16 1.7 Participation by Industry Organizations
.7 1
1.8 Role of the Region During Activation 19 1.9 -
Upgrading or I)owngrading an Investigation 1 10 1.10 Exhibits 1 12 Generic Confirmatory Action letter 1 12 Generic Order to Show Cause 1 14 Background Information (compiled by the Region) for the BT B rie fi n g.................................
1 17 Example EDO Memorandum to the Commission 1 18 NRC Region I Mobile Nmulc<tructive Evaluation 1 aboratory..... 1 22 Agreement on_ Waiver of Compensation, Conflicts of Interests and Releases of Investigation Information for Industry Representatives Participating in r
Incident investigation Teams (llTs) 1-26 EDO Memorandum on Waiver of Commission Policy on Avoidance of Organizational Conflicts of Interest for Industry Participants 1 30 Region Action Item Checklist for Activating an llT 1-32
- GUIDELINE 2: CONDUCTING AN INCIDENTINVESTIGATION 2-1 2.1 Purpose 2-1
2.2 Background
2-1 2.3 IIT Lead Responsibilities 7'
L 2.4
-Role of the Region in Support of the Conduct of the Incident investigation..............................
2v 2.5 -
Initial Actions by the llT trader 2-3 2.6
- Entrance Meeting with the Licensee 2-5 2.7 Plant Tour of Affected Equipment and Systems 2-7 2.8
-laterviewing Personnel 2-7
.9 Sequence of Events 2-7 1
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~.. -,. - -. - - - - - -,.. -
2.10 Quarantined Equipinent List (OEL) and Troubleshooting Action Plans (TAPS) 2-8 2.11 IIT Coordinat:on Meetings 2-8 2.12 Status Reports 29 2.13 Collection of Information and Recordkeeping Activities 29 2.14 Responding to Press Inquir:es 2 10 2.15 Identifying Additional Expertise and Outside Assistance.......... 2-10 2.16 Industry Participation in the investigation 2 10 2.17 Parallel Investigaticins.......................,........... 2 11 2.18 Referral of Investigation Information to NRC Offices 2-11 2.19 Confidentiality 2-11 2.20 Subpoena Power and Power t, Administer Oath and Affirmation 2 12 2.21 Return Site Visit 2-12 2.22 Report Preparation and Presentation 3 12 2.23 Exhibits
' :3 IIT Team Leader Checklist 2 13 Press Conference Guidance 2-15 Generic Bulletin Board Notice 2 16 Example llT Preliminary Sequence of Events 2 17 Example Preliminary Notification Report 2-20 GUIDELINE 3: CO N D UCI'I NG I NTE R V I EWS.....................
31 3.1 Purpose 3-1 3.2 B w kgcound 3-1 3.3 Scheduung and Team Attendance..........
31 3.4 Third Pany Attendance 3-2 3.5 Interview Guidelines 32 3.6 Exhibits 3-5 Guidelines for Review and Availability of Transcripts..
3-5 GUIDELINE 4: TREATMENT OF QUARANTINED EQUIPMENT 41 4.1 Purpose 41
4.2 Background
41 4.3 Ouarantined Equi [ ment List (OEL) 42 4.4 Troubleshooting Action Plans........
42 4.5 Exhibits 4-6 Generic Guidelines for Troubleshooting the Probable Causes of Equipment Anomalies 4-6 Example Troubleshooting Action Plan (TAP) 4-8 vi
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- FOLLOWUP STAFF ACTIONS..................,.....
51 5.1 -
P u rp o s e............................................. - 51 5.2 B ackgrou n d..........................................
51 5.3 Writing and Publishing Guidelines 51 5.4 Report Writing G tiidelines...............................
51 5.5 Graphie Guidelines 54 5.6 Publication Forms 55 5.7 Distribution of the Advance Copy..................
55 5.8 Distribution of the Published NUREG 5-6 5.9 -
Staff Action Determination and Assignment 56 5.10' Staff Action Status Reporting............ -.................
5-6 5.11 Schedule 57 5.12 Exhibits 59 Example Report Outline 5-9 IIT Team Leader Checklist 5 10 Example Staff Actions 5-11 i
APPENDICE3 NRC Incident Investigation Program.
A.
NRC Manual Chapter 0513..........
A-1
-B.
Augmented Inspection Team, NRC Inspection Manual Chapter 0325............................
B-1 C.
Memo from W. J. Dircks to the Commissioners,
Subject:
Incident Investigation Program, SECY-85 208, dated June-10,1985.........................................
C-1 D.
Resolution of Industry Comments on the Draft
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Incident Investigation Procedures...................,............
D-1 l"
E.
Resolution of Regional Workshop Questions Regarding the Incident Investigation Program E-1
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vii
PREFACE l
The objective of the incident Investigation Program (IIP) is to ensure that operational significant events are investigated in a systematic and' technically sound manner to gather information pertaining to the probable causes of the events, including any NRC contributions or lapses, and to provide appropriate feedback regarding the lessons of experience to the j
NRC, industry, and public.11y focusing on probable causes of operating events and identi6 cation of associated corrective actions, the results of the llP process improve nuclear
' safety by ensuring a complete technical and regulatory understanding of signincant events.
incident Investigation Teams ensure that significant operational events are investigated in a i
manner that is timely, objective, systemat_ic and technically sound; that factual information pertaining to the event is documented; that probable cause(s) are ascertained; and that a i
complete technical and regulatory understanding of such an event is achieved.
These guidelines were developed and rganized by the Of6ce for Analysis and Evaluation of o
Operational Data (AEOD). -In early 1986, a draft of the guidelines were provided to all the -
owner's groups, the Institute of Nuclear l'ower Operations (lNPO), and the Nuclear Safety Analysis Center (NSAC) for comment. Between January 29,1987 and March 11,1987, i
AEOD held five regional workshops to acquaint licensees with the IIP. In August 1991, the
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guidelines were revised to c!carly denne the roles and responsibilities of the team leader, provide guidance on the followup and closcout of NRC staff actions, address lessons learned from incident investigations, and incorporate more current illustrative exhibits. The guidelines were also revised to incorporate changes to NRC Manual Chapter 0513,'NRC Incident investigation Program."
These guidelines will foster uniformity, consistency, and thoroughness in llT investigations, while permitting teams the Dexibility to accommodate the diverse nature and scope of future investigations.-
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GUIDELINE 1: ' ACT!VATING AN INCIDENT INVESTIG ATION TFAM (IIT)--
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' Guideline 1 provides guidance to NRC management for activating an Incident Investigation Team (llT) response to a signiGLant operational event at an NRC-licensed facility,- This guideline also provides direction for activating an llT and selecting the number and kinds of expertise required for a timely, thorough, and systematic investigation.
1.2 IMckground l
The scope, objectives, authorities, responsibilities, and basic requirements for the investigation of signi0 cant operatior,al events at reactor and non-reactor facilities licensed by.
the NRC are deRned in *NRC incident investigation Program," Directive 8.3 (see Appendix -
A).-The Executive Director for Operations (EDO) approves the investigation of a signincant operational event by an llT, in part, on the basis of recommendations by NRC headquarters
' and regional offices concerning the safety significance of the event. The EDO also determines the composition of the llT and approves team members (including composition) based on recommendations by senior NRC management.
The Incident investigation Program encompasses investigatory responses by an llT and the less formal response by an Augmented Inspection Team (AIT). The major differences-between an AIT and an IIT a e that:
an IIT investigates the most safety-significant operational events relative to the
. risk to public health and safety, l the HT leader and ~ members have not had significant involvement with licensing and inspection activities at the affected facility, industry representatives may participate on an llY under the pros %is of a Memorandum of Agreement between NRC and the Institute of Nuuar Power Operations (INPO).
Events of lesser safety significance whose facts, conditions, circumstances, and probable-causes ivould contrib ste to the regulatory and technical understanding of a generic safety concern or another important lesson will be assessed by an AIT. NRC Inspection Manual Chapter 0325, " Augmented Inspection Team" is the procedure for activating and conducting an AIT response, maintained by the Office of Nuclear Reac'or Regulation (NRR) (see Appendix B).
1-1
1.3 Selection and Scooe of Events for llT I{esame The recommendation to ihe EDO for activating an !!T should include the identi6 cation of the potential safety signi6cance of the event. The threshold for activating an llT is intended to be high and limited to those operational events which are expected to have signiGeant safety implications. Historically, the events investigated by an llT have generally involved multiple failures in plant systems, which resulted in system responses that were not part of the design bases, and substantially reduced the safety margins that ensure public health and safety.
Signi6 cant operational events that should be considered for an IIT response may include one or more of the following characteristics:
(1)
A signiGcant release of radioactive material to unrestricted areas, or overexposure of personnel to radioactive material.
A significant overexposure or release of radioactive material is an event which substantially exceeds the regulatory limits in 10 CFR Part 20, or has the potential for significant radiation or chemical exposure to members of the public. Such events include those which can occur at both reactor and nonreac-tor facilities, and transportation events subject to NRC jurisdiction. In evaluat-ing these events, primary attention should focus on the onsite and offsite personnel health and safety concerns, and consider the offsite protective actions, and the potential generic aspects of the event. The inadvertent shipment of a radiographic source from Korea to Amersham Corporation, Burlington, Manachusetts, in 1990 is an example of an event of this type. An IIT was established because of the nature and potential radiological health consequences and the generic questions the event raised. The UF6 cylinder rupture at the Sequoyah Fuels Facility in 19S6 also falls in _this category because of the large ielease of hydrogen Guoride (a reaction product of UF6 and airborne moisture) to the environment, and the involvement of multiple agencies in response to the event. Potential offsite (i.e., public health) radiological consequences are a primary concern and thus, should public health and safety be significantly impacted or threatened, an !!T response wo'dd be appropriate.
(2)
Plant operation that exceeded, or was outside of the design bases of the facility.
Such events include those where a valid chaPenge existed yet both trains of a safety-related system were lost, or events that were not analyzed in the Updated Safety Analysis Report; e.g., the loss of offsite power and failure of onsite power on demand at Vogtle (1990), the total loss of feedwater at Davis-Besse (1985), the precursor anticipated transient without scram (ATWS) at Salem (1983), the failure on demand of the safety injection system at San Onofre (1981), and the fire at Browns Ferry (1975).
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-(3)
Events that involve or appear to involve a major denciency in design, construction or f
operation having potential generic safety implications.
iI Events with this characteristic would include an unplanned criticality, or multiple failures in safety equipment or procedural controls that had a-j significant potential for an unplanned criticality. An unplanned criticality is a i..
condition whereby fissionable materials are unintentionally assembled so as to l _
occur at fuel cycle facilities, such as fuel processing and fabrication plants, and produce an uncontrolled chain reaction. Such events include those which can at power and nonpower reactor facilities. In general, reactor operations i
involving approaches to criticality, where criticality is either achieved l
unexpectedly or not achieved as expected, will not fall within this criterion if operations are within established limits.
i Examples of events involving a major denciency in design or operation having significant potential safety implications include the loss of integrated control system at Rancho Seco (1985), the water hammer event at San Onofre (1985),
the failure of the reactor cavity seal at IIaddam Neck (1984), the inadvertent criticalities during refueling with the reactor vessel head removed at Millstone
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(1976) and Vermont Yankee (1973).
(4)
An event that Nd or should have led to a site area emergency.
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This type of event would involve activation of the NRC Operaticas Center and
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would normally involve multi-agency responses. Examples of such events l
include the loss of offsite power and failure of onsite power on demand at l:-
Vogtle in 1990, and the UF6 cylinder rupture at the Sequoyah Fuels Facility in L
1986.
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(5)
. A safety limit of the licensee's Technical Specifications was exceeded.
Safety limits are defined for each reactor in the technical specifications, e.g for a PWR, reactor coolant system pressure exceeding the maximum allowable, or the combination of thermal power, pressurizer pressure, and the appropriate limit for n and n-1 loop operation. An example for a boiling water reactor.
(BWR) was the Oyster Creek loss of coohnt event (1979) which exceeded the i
I safety limit for minimum core inventory water level requirements.
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A significant los3 of fuel integrity, the primary coolant pressure boundary, or the primary containment boundary of a nuclear reactor.
Examples of events with this characteristic include the steam generator tube rupture at Ginna (1982), the loss of coolant outside the containment structure at llatch (1982), and signi6 cant reactor coolant pump seal leaks at Robinson (1981) and Arkansas Nuclear One (1980).
(7)
Loss of a safety function or multiple failures in systems used to mitigate an actual event.
Examples of events with this characteristic include the failure of the auxiliary feedwater system at Davis-Besse (1985), the partial failure to scram at Browns Ferry (1980), the precursor ATWS event at Salem (1983), and the failure of the safety injectior. system on demand at San Onofre (1981).
(8)
An event that warrants an independent investigation because ofits complexity, uniqueness, lack of understanding, or is of interest to the Commission, l
1.4 IIT Discussion and Activation proem Activating an IIT in response to a significant operating event at a power reactor normally involves the coordinated activities of the appropriate Region, AEOD, NRR, and the EDO. If the affected facility involves fuel cycle, byproduct material, uranium recovery, or waste management licensees, the Of6cc of Nuclear Material Safety and Safeguards (NMSS) would also participate. The decision to activate an llT should include consideration of public health and safety (protection of public/ environment from radioactive release or contamination) and be based on the safety issues, potential generic implicat:ons, personnel errors, or equipment failures associated with the event related to the characteristics discussed in Section 1.3.
The llT is activated and will begin its investigation as soon as practical after the safety significance of the operational event is determined to ensure that the facts, conditions, circumstances, and probable causes are ascertained. if there is an NRC incident response, the investigation will begin after the incident response is deactivated.
The following guidelines should be used to recommend and activate an llT:
(1)
Upon their notification of a significant operational event, the Directors of NRR or NMSS, AEOD, and the Regional Administrator should jointly discuss and assess the safety significance of the event to determine whether an IIT or an AIT is required.
For activating IITs, they should assess the level of investigatory response based on the criteria in NRC Manual Chapter 0513 (see Appendix.A) and this guideline, and for AITs, they should use the criteria in NRC Inspection Manual Chapter 0325, Augmented Inspection Team (see Appendix B).
1-4
(2)
Regional Administrators, in coordination with NRR or NMSS, are to determine those operational events warranting investigation by an AIT; and as soon as it becomes clear that at least an alt is warranted, preferably before an AIT is actually established, constdt with the Directors of NRR or NMSS, and AEOD to consider whether an llT response is appropriate. If an llT is agreed upon, the initiating office makes that recommendation to the EDO. Differences among offices concerning whether an AIT or IIT is the proper response are submitted to the EDO for resolution.
(3)
For events which the EDO agrees warrant an llT, the EDO selects the llT leader and team members (see Section 1.6). The Director, AEOD* will take the lead in coordinating with NRR or NMSS, and the appropriate Regional Administrator regard-ing the expertise and the availability of individJals, and the preparation of the team's written charter delineating the scope of the investigation, for approval by the EDO
{
(see Section 1.5). For reactor events, the Director, AEOD, will contact the Group Vice President for Industry and Government Relations, INPO, who will coordinate with various industry groups to facilitate indus,'y participation on the llT (see Section 1.7).
(4)
The EDO assigns a due date for the report of about 45 days after the llT has been activated. The EDO should consider assigning the due date to coincide with a Monday so that all available administrative support will be directed to preparing the final report during the preceding weekend.
(5)
After the llT leader and members have been selected, AEOD provides the adminiera-tive support necessary to dispatch the llT in a timely manner. This support includes travel authorizations, tickets and advances during off-duty hours, logistics, and other site-speciSc information, including site access, and other site arrangements. AEOD staff will accompany and provide administrative support to the IIT.
(6)
The Regional Administrator issues a Confirmatory Action Letter (as illustrated by Exhibit 1-1) to the affected licensee. The Confirmatory Action Letter (CAL) confirms a licensee's statement of intent and action, in the unlikely event that the licensee and Regional Office cannot agree on the actions that the NRC believes are necessary, the Director of NRR may issue an order to show cause ensuring that information related to the event is preserved. Exhibit 1-2 shows a generie Order. Even where the licensee agrees to the terms of the CAL, those commitments may be confirmed by Order at a later time if NRC management deems it appropriate.
(7)
The Regional Administrator will designate a regional representative to interface with the IIT. The regional representative should initially ensure that a brie 6ng package is available to the llT when it arrives onsite (see Exhibit 1-3).
The Director, AEOD may designate another senior AEOD managcr within AEOD to be responsible for carrying out office functions related to the IIT.
1-5
O (8)
The Director, AEOD prepares for the EDO's signature a memorandum informing the Commission of the activation of an llT and the scope of the investigation (team charter). Exhibit 1-4 shows an example memorandum. The Director, AEOD also contacts the Director, Ofnce of Governmental and Public Affairs (GPA) and assists in the preparation of the NRC press release.
1,5 Scope of the_lnmjitalien Following the decision to activate an llT, the scope of the investigation should be quickly evaluated and documented in the form of a team chatter. The scope of an llT investigation should include conditions preceding the event, event chronology, systems response, human factors considerations, equipment performance, precursors to the event, emergency response (NRC, and licensee), safety signi6cance, radiological considerations, and whether the regulatory process and activities preceding the event contributed to it. A detailed team charter delineating the scope of the investigation will be provided to the llY leader. The charter should be provided as an enclosure to the EDO's memorandum notifying the Commission that an llT has been established (see Exhibit 1-4'. The basis for the llT shall be included in the written charter.
The scope of the investigation does nelinclude:
Assessing violations of NRC rules and requirements; and Reviewing the design and licensing bases for the facility, except as necessa y to assess the cause for the event under investigation.
Assessing reasonable assurance of effsite emergency response capabilities.
Followup actions associated with the llP process do not necessarily include all licensee actions associated with the event, nor do they cover NRC staff activities associated with normal event followup (such as authorization for restart, plant inspections, corrective actions, or possible enforcement items). These activities are expected to be defined and implemented through the normal organizational structures and procedures. NRC staff may utilize / review information obtained during the IIT investigation, including transcripts, and may request guidance from IIT members on matters concerning actions associated with the llT report / investigation as input to or as part of seperate investigations.
1.6 Team Selection.anJ Comoosition In addition to identifying the potential safety significance of the event, the recommendation to the EDO for activating an llT investigation should address the types of expertise needed for the team. The IIT membership selection should be based on the following guidelines:
1-6
(1)
Determine the number of team members and their areas of technical expertise based on
\\
the type of facility and characteristics of the event, For a reactor event, event, the
. team may include experts in reactor systems, human factors, operations (licensed operator), and mechanical or electrical systems. Additional memben could include specialists in core physics, radiological assessment, health physics, chemistry, materials, safeguards, emergency preparedness, or other specialized areas.
(2)
Seleu the llT leader (who is an NRC manager from the Senior Executive Service (SES)) and team members based on their expertise, potential for contributing to the i
event investigation, freedom from significant involvement in the licensing and inspectior of the facility involved or other activities associated with issues that had a direct impact on the couise or consequences of the event, and full-time participation for the duration of IIT activities. To the extent practical, select the llT leader and team members from approved rosters of candidates maintained by AEOD. Can-didates should be certiGed through the completion of formal training in incident investigadon.
(3)
Obtain technical contract support for the IIT as needed, Contractor assistance should-'
be limited to services that are not available within the NRC, e.g., independent laborat-ory analyses, computational support and testing. Within the NRC, there are also capabilities and expertise that can contribute to the IIT activities, e.g., the NDE van and equipment (See Exhibit 1-5 for description of NDE van equipment capabilities),
control room simulators, photography, and computer analyses. AEOD will provide the resources and administrative support necessary to procure the services requested by the team leader, The Assistant General Counsel for Enforcement will provide legal assistance as necessary.
1.7
[Mrticipatica by Industry Organi7ations When an llT is activated for a power reactor event, industry representatives should be
-informed and their participation should be encouraged. Their participation brings both an industry perspective to the investigation and expert knowledge of plant hardware and practices in numerous areas, In addition, industry participation would facilitate in the feedback of factual information regarding the event to the industry for the self initiation of potential preventive and/or corrective ections. Such participation should also help expedite the event investigation and the identi6 cation of the generic applicability'of signincan' issues. Industry
- participation is consistent with and fully supportive of the Incident Investigation Program objectives.
-After the EDO determines that an IIT response is warranted, the Director, AEOD 'should -
contact the Group Vice President for Industry and Government Relations, Institute of Nuclear
- Power Operations (INPO), who will inform the various industry groups (Nuclear Safety L
Analysis Center (NS AC) and the owners' group for the affected plant) regarding the IIT and coordinate their participation with the IIT in the investigation. The Director, AEOD may 1-7
.c
indicate the type of technical expertise that would be desirable for the industry representative to nave in order to ensure a proper range of disciplines on the llT The Group Vice Pre _ue'it for Industry and Government Relations, INPO will be the contact with NRC to recommend the industry representative (s) using the same criteria by which the NRC uses to select NRC members i.e., (1) specific technical expertise: (2) potential for contributing to the event investigation; (3) no previous significant involvement with tiie affected plant or utility's activities or with other signincant issues associated with or directly related to the cause, course or consequences of the event; and (4) full-time participation for the duration of IIT activities. As part of its nomination of industry participants, INPO will submit a statement signed by each industry nominee regarding proprietary information, con 0ict of interests, procedures for handling differences of opinion and prNedures for handling release of information. A signed statement by the nominees to these agreements will be provided to the NRC as part of the nomination process (Exhibit 1-6).
The industry representatives and the NRC members qualineations will be reviewed by the EDO or upon his direction, the Director, AEOD to ensure that all team members are suitably qualified and meet the selection criteria. The EDO approves tre IIT members on a case-by-case basis (i.e., each is reviewed and approved individually). In addition, pu'suant to the waiver procedures specified in 41 CFR Part 20-1.54, " Contractor Organizational Conflicts of Interest," the waiver regarding the policy of avoiding organizational conflicts of interest j
provided ia Exhibit 1-7 should be executed for the purposes of allowing the participation of industry personnel on NRC llTs.
l After the EDO approves the composition and membership of the llT, all members will be advised of the location and time for the first llT organizational meeting. The Group Vice President for Industry and Government Relations, INPO will be requested to provide assistance in coordinating with *he affected licensee in obtaining site access for the industry representatives. The 11T leader will organize and assign the various investigative activities to NRC team members. All representatives should be relieved of other duties until the investigation is completed and the investigation report is issued. The EDO may relieve from the llT any personnel who will not remain with the investigation until the completion of the report, or other personnel for reasons he/she deems appropriate.
The NRC has agreements addressing the attendance of certain state representatives at NRC meetings with licensees, including plant inspections. Such state attendance does not extend to IITs. Non-NRC IIT members are expected from organizations directly involved with the analysis and evaluation of operational experience, such as INPO. Requests by state and/or local officials to participate on an llT will be handled on a case-by-case basis. As noted above, representatives from non-NRC organizations would be expected to have the same level of qualifications as NRC personnel and selected in accordance with the same criteria by which NRC personnel are selected.
9 l-S
____._.__m_._____
f 1.8 Role of the Region During Activation A region action item checklist for activating an llT is provided in Exhibit 1-8. The responsibilities of the Fegion related to an llT activation are to:
(1)
Provide input to the discussion and decision proccss on recommending the need for activating an llT.
1 (2)
Provide input to the Director, AEOD regarding the desired expertise and the llT's written charter delineating the scope of the investigation, (3)
Designate a regional representative to coordinate regional activities with the IIT.
(4)
Issue a CAL (as illustrated by Exhibit 1-1) to the affected licensee confirming the licensce's commitment that, within the constraints of ensuring plant safety, relevant failed equipment is quarantined and subject to agreed upon controls; that r farmation i
related to the event is preserved; and that the plant is maintained in a safe shutdown condition until concurrence is received from the NRC to restart, Completion of an llT investigation and issuanec of the report is not necessarily required for plant restart, (5)
Prepare a briefing package prior ta the IIT's arrival. This package should provide sufficient background inf< rmation for ilT members to quickly grasp unique aspects of the plant design and relevant data relateo to the event. The regional representative should coordinate with the IIT team leader on the briefing package information -
necessary to support the llT, For power reactors, this type of information should be readily available from the resident inspector's of0cc, where most of the data would I
normally be compiled as part of the resident inspector's onsite followup to significant events. Exhib:t 1-3 lists information that could be provided in the brienng package,
_(6)
Provide public affairs assistance, as needed. This may include assigning a Public Affairs OfGcer onsite, (7)
Negotiate with the licensee for suf0cient office space for the IIT, if arrangements cannot be made to i. cate the team onsite, the Region should identify an alternate location as close to the site as possible. Accommodations should include:
a conference room with adequate space to house the IIT j
o at least two rooms for conducting interviews adequate number of telephones (including at least one conference call and/or speaker telephone) i.
l l-9 o
an additional area for reviewing transcripts and performing administrative functions (9)
Provide administrative support, which could include:
obtaining transcription services providing full-time secretarial support for lii administrative workload obtaining escorted or unescorted site access for teans members, as determined by the team leader (10)
Coordinate the entrance meeting and plant tour for the !!T with the licensee.
1.9 1]pgrading or Downerading an Invegi atina t
Adequate information is not always initially available or accurate enough to determine whether the safety significance of an event warrants an AIT or an llT. Thus, an investigation coubt be subsequently upgraded or downgraded based on evolving available information in general, the safety significance of the event will be the criterion guiding the investigatory
- response, Upgrading or downgrading of an investigation man confuse the licensee and cause additional disruption to ongoing activities. Accordingly, the llT leader must minimize the adverse impact of such a change by ensuring that frequent and meaningful communication occurs among the AIT, ilT, and the licensee during the critical transition period.
The following guidelines are used to upgrade an AIT to an llT:
(1)
In defining the scope of an AIT investigation, the Regional Administrator includes a provision for the AIT leader to continually evaluate the safety significanc cf the event after arriving onsite. Ilased on the AIT leader's assessment, the Regional Administrator determines whether the event warrants consideration as a candidate for an ilT response.
(2)
Should the Regional Administrator determine that the event warrants consideration as an ilT response, the process for activating an llT would be followed as described previously in this guideline, e.g., a conference call would be held between the Region, NRR or NMSS, and AEOD (and possibly the AIT leader).
(3)
The AIT leader would usually be replaced by an llT leader selected by the EDO; however, all or some AIT members may be retained for the llT based primarhy on the independence of the individual with rerpect to their prior activities related to the affected licensee and the issues involved in the event.
1-10
4.-._.._.__..----
L j
e O
4 (4)-
The alt remains onsite to assist the llT until the llT leader believes that a successful l
i transition has been achieved, i
i-The following guidelines are used to downgrade an llT to an AIT:
i (1)
In consultation with the IIT leader, the EDO decides that the event lacks the safety significance to warrant continuance as an llT.
I-i (2)
The EDO assigns responsibility to the Regional Administrator to direct the IIT-to-AIT trar'sition, including the release of the llT leader, industry representatives, and some or all of the NRC team members.
L i
(3)
The llT leader is usually replaced by an AIT leader selected by the Regional Administrator.
1 l
(4)-
The AIT follows the NRC Inspection Manual Inspection Procedure 93800, which'.
l guides the response of the AIT.
(5)
The Director, AEOD, prepares a memorandum for the EDO's signature informing the Commission that the llT has been de-activated based on the lesser safety significance of the event. The Director, GPA, is also informed at this time.
i i
F 5
9 i
i f
L i
o f
l n
i 9 1
1-11
1.10 Exhibits Exhibit 1-1 Generic Confirmatery_bIlien ! etter Docket No.
[ Licensee Name]
[ Address]
==Dear
- ==
On [date), [brief description of event].11ecause of the potential significance of this incident to public health and safety, the NRC's Executive Director for Operations has established an Incident Investigation Team (llT) to investigate the circumstances surrounding the incident.
[ Include as appropriate a brief description of the event's signiGeance).
This letter connrms the conversation on [date] between and of my staff related to this incident. With regard to the mauers discussed, we underst:md that you have agreed to cooperate with the IIT and you have taken or will promptly take the following actions necessary to suppon this investigation:
(1)
'lhe facility will remain in cold shutdown (or other appropriate mode description]
until the Regional Administrator is satisfied that appropriate corrective action has been taken and the plant can safely return to operation.
(2)
The licensee will prepare a list of equipment that failed or malfunctioned during the event, and had an impact on the sequence of events. The licensee will ensure that the equipment identi6ed on this list is not disturbed prior to release by the IIT. In this regard, work in progress or planned on this equipment will be held in abeyance so that evidence of the equipment's functioning during the incident will not be disturbed. Perscnnel access to areas and equipment subject to this quarantine will be minimized, consistent with plant safety.
The licensee is responsible for quarantined equipment and can take action involving this equipment it deems necessary to: (1) achieve or maintain safe plant conditions, (2) prevent further equipment degradation, or (3) test or inspect as required by the plant's Technical Specincations. To the maximum degree possible, these actions should_bc coordinated with the llT leader in advance or notincation made as soon as practical. The llT leader may authorize a release, in whole or in part, of those areas or equipment subject to the quarantine upon a determination that the IIT has received sufGe!ent information concerning the areas or equipment requested to be released, or to permit necessary troubleshooting of the equipment, required testing or maintenance to be performed.
i 1-12 l
i l
Jixhibit 1-1 (continueA) 2-(3)
All records will be preserved intact that may be related to the event and any surrounding circumstances that could assist in understanding the event. Such records shall be retained for at least two years following the event whether or not required to be retained by regulation or license condition.
(4)
The licensee will make available to the llT for questioning such individuals employed by the licensee or its consultants and contractors with knowledge of the event or its causes as the llT deems necessary for its investigation.
(5)
The licensee will ensure that any investigation to be conducted by the licensee or a third party will not interfere with the IIT im stigation. The licensee will advise the llT of any investigation to be conducted by the licensee or a third party.
Reports of such investigation will be promp'ily provided to the llT.
Issuance cf this confirmatory action letter does not prechide the issuance of an order formalizing your commitments. The above commitments may be relaxed for good cause.
If your understanding differs from that set forth above, please call me immediately.
Sincerely,
[Name]
Aegional Administrator cc: IIT Leader NRC Oftice Directors Regional Administrators 1-13
O Exhibit 1-2 iltritritOIdenqEhew Cau.it UNITED STATf S OF AMERICA NUCLEAR REGULATORY COMMISSION In the Matter of
)
)
Docket No..__
[ LICENSEE'S NAME]*
)
)
[ Facility Name]
)
License No.
ORDJiR TO SHOW1ti.USE_(.1MMElli.KfEI,Y EEEECIlYlD i
1.
[ Licensee's namej (the Licensee) holds License No.
, which authoritcs the Licensee to operate the iname of facilily] (Facility) in [1m;snoj.
II.
[Brief description of the event in a paragraph or two]
III.
Tbc NRC Executive Director for Operations has established an incident Investigation Team (Irl) to investigate the circumstances surrounding the incident described in Section 11 of this Order. An llT was establis.hed because [ describe in one or two sentences the significance of the event],
The investigation is required to obtain necessary informatica to assure sufficicnt understanding of the cause of the event so that a determination may be made as to Nhat corrective actions wil.1 be sufficient to provide reasonable assurance that operation of the facility will not create an undue risk to the public health and safety. The licensee's full coopetution is required during the investigation to permit a complete and timely investigation. [ Indicate whether CAL was issued and reason why this Order is being issued in view of previous CAL., e.g.,
violation of terms of CAL or desire to formalize CAL commitments by Oraer.)
Accordingly, I have determined that the public health and safety requires that the facility license be suspended until the llT investigation is complete, the event evaluated, and ap-propriate corrective action taken and, therefore, that this Ocder be immediately effective.
- Bracketed and underlined areas must be completed.
1-14 g
r f
i i
lhhibiLb2Jeontinued)
IV.
In view of the foregoing, pursuant to Sections 103 [or appropriate section for materials license),161(b), (c), (i), and (o),182 and 186 of the Atomic Energy Act of 1954, or amended, and the Commission's regulations in 10 CPR 2.202 and Part 50 [or other ap-propriate regulations), IT IS HEREBY ORDERED, EFFECTIVE IMh1EDI ATELY THAT:
A)
The licensee shall maintain the facility in cold shutdown (or other appropriate mode description until the undersigned] Director [or appropriate Regional Administrator) determines that there is a sufDelent unders'anding of the causes and consequences of the incident and suf6cient corrective action has been taken such that resumption of operations poses no undue risk to public health and safety; B) he licensee will ensure that the equipment involved in the incident is not d_isturbed prior to release by the IIT. In this regard the licensee shall hold in abeyance any work in progress or planned on equipment that failed or malfunc-tioned during the event, and had an impact on the' sequence of events so that evidence of the equipment's functioning during the incident will nat be disturbed.
This c ^nsee shall minimize, consistent with plant safety, persomiel access to areas A
and equipment subject to this quarantine. The licensec is responsible for quaran--
tined equipment and can take action involving this equipment it deems uccessary to: (1) achieve or maintain safe plant conditions, (2) prevent further equipment degradation, or (3) test or inspect as required by the plant's Tecimical Specifica-
. tions. To the maximum degree possible, these nctions should be coordin.ted with J'
the IIT aader in advance or notincation made as soon as practicah The IIT leader may authorize a release, ia whole or in pan, of those areas or equipnMnt subject to the quarantine upon a determination that the !!T has received sufficient information concerning the areas or equipment requested to be released, or _to permit necessory troubleshooting of the equipment, required testing or maintenance; C)
The licensee shall preserve imact all records that nny be related to the event and ary surrounding circumstances which could assist in understandinp, the event.
Such recoids shall be fetained for at least two years following the event whether or not required by regulation or license cotidition to be retained;-
D)
The licensee shall ma.ke available to the 11T for questioning such individuals employed by the licensee or its consultants and contractors with knowledge of the event,- its causes, or con.quences as the IIT deems necessary for its investigation; -
l l-15
1 O,
l Eahibill-2 (conti11ued i
-1 E)
The licensee shall ensure it at any investigation to be conducted by the licensee or a third party will not interfere with the llT investigation. The licensee thall advise the llT of any investigation to be conducted by the licensee or a third party.
Reports of such investigation shall be promptly provided to the IIT.
V.
)
The licensee n'ay show cause, within 30 days after issuance of this Order, why it should not have been required to comply with the provisions specified in Section ill by filin.<; a written answer under oath or affirnation setting forth the matters of fact and law en which the Ucensee relics, The licensee my answer this Order, as provided in 10 CFR 2.202(d), by consenting to the provisions specified in Section 111 abeve. Upon the licensee's consent to the provisions sct forth in Section 111 of this Order or upon failure of the licensee to file an answer within the specified time, the provisions set forth in Section 111 shall be fmal without further order.
VI.
The licensee, or any other persor' whose interest is adversely affected by this Order, may request a hearing within 30 days of the date of this Order. Any answer to this Order or any request for a hearing shall be submitted to the Director, Office of Nuclear Reactor Regulation U.S Nuclear Regulatory Commission, Washington, DC 20555 with a copy to the Director, Office of General Counsel at the same address and to the Regional Administrator, [Adsjm].
If a person other than the licensee requests a hcaring, that person shall set forth with par-ticularity the manner in which the petitioner's interest is adversely affected by this Order and should address the criteria set forth in 10 CFR 2.71d(d). If a hearing is requested by the licensee or any person who has an interest adverby affected by this Order, the Commission willissue an order designating the time and place of any such henring. Any answer or request for a hening shall not stay the immediate effectiveness of Section 111, of this Order.
In the event a hearing is held, the issue to be considered at such hearing shall be whether, ihis Order should be sustained.
FOR THE U.S. NUCLEAR REGULATORY COMMISSION
{Name), Director Office of Nuclear Reactor Regulation Dated at Rockville, Maryland, this _.
day of 19 _
O l 16 4
I Exhibit 13 Jhrkrnond information {cartut[ed by thy _lieg on) fotihg,1).LUfiting i
f Prior to the llTs arrival, the Region prepares a briefing package to acquaint team membus with the unique aspects of the plant design and data related to the event. This package may contain the folic. wing information:
Preliminary Sequence of Events Confirmatory Action Letter and/or Order Licensee Post-Trip Review i
Control Room Operator Logs Computer Alarm Printout / Strip Chart Recordings Applicable Licensee Procedures Applienble 1icensee Technical Specification Requirement.s Preliminary No:ification Licensee Press Release NRC Press Release Licensee Organization ( hart Diagram of Facility Layout Applicable Piping and Instrumentation Drawings Applicable Wador Drawings and Manuals o
SALP Reports Applicable inspection Reports Applicable Licensee Event Report.s Applicable Maintenance Logs Applicable Electrical Logic Diagrams Prelirtinaiy Operator V'ruten Statements 1-17
Exhibit 14 liMtmpk_EDO hiemorandum to the Coittmission h1 arch 23,1990 h!Eh10RANDUh1 FOR:
Chairman [Name]
Commissioner [Name]
Commissioner [Namel Commissioner [Name]
Commissioner (Name]
FROhi:
[Name]
Executive Director for Operations
SUBJECT:
INVESTIGATION OF Tile h1ARCil 20,1990 EVENT AT VOGTLE NUCLEAR POWER PLANT, INVOLVING LOSS OF OFFSITE POWER AND FAILURE OF ONSITE POWER ON DEh1AND AT UNIT 1 On hiarch 20,1990, at 9:58 a.m. EST, the licensee for the Vogtle Nuclear Power Plant notined the NRC that they had declared a Site Area Emergency for Unit I due to a loss of offsite power concurrent with a loss of onsite emergency diesel generator (EDG) capability.
Tiie loss of offsite power was caused by a truck accident in the switchyard. At the time of the incident Unit I was in cold shutdown with the B reserve auxiliary transformer and the U EDG out of service for maintenance. The A EDG started as designed but immediately tripped.
Thirty-six minutes into the event, the A EDG was manually started, at which time core cooling was reestablished to Unit ' The Unit I reactor coolant temperature peaked at 136 degrees Fahrenheit and stabilized at 100 F after emergency ac power was restored. The licensee downgraded the event to an Alert at 10:15 a.m. ES'1 based on the restoration of onsite power.
Unit 2 reactor also tripped from 100 percent power as a result of the truck accident, but did not lose offsite power. At 11:29 a.m. EST the B reserve auxiliary transformer was re-energized, restoring normal power to the engineered safeguards buses.
An Augmented Inspection Team (AIT) was immediately sent to the site by Region 11 to investigate the event. However, because of the safety significance and the potential reguhtory questions the event raises, I have requested AEOD to take the necessary actions to upgrade the current AIT to a seven member NRC Incident Investigation Team (IIT). Arrangements are being made under the provisions of a hiemorandum of Agreement with the Institute of Nuclear Power Operat ons for industry participation. The team is to: (a) fact End as to what hap-pened; (b) identify the probable cause as to why it happened; and (c) make appropriate Ondings and conclusions which would form the basis for any necessary follow-on actions.
1-18
Exhibit 1-4 (cfstiingel)i o
T1.e Commissioners The team will report directly to me and is comprised of: [name], (RV) IIT Leader; [name],
(NRR); [name), (AEOD); [name), (AEOD); [name), (NRR); [name), (NRR); and [name),
(RI). Enclosed is the charter for the llT to use in the review of the event.
The llT was selected on the basis of their knowledge and experience in the fields et reactor systems, reactor operations, human factors, and power distribution systems. Team members have no direct involvement with Vogtle. The additionst team members and llT leader are currently enroute to the site.
The licensee has agreed to preserve the equipment in accordane; with the Confirmatory Action Letter which was issued by the Regional Administrator on March 23,1990. The licensee has also agreed not to take Vogtle Unit I critical until concurrence is received from the NRC.
The llT report will constitute the single NRC fact-finding investigation report, it is expected that the team report will be issued within 45 days from now.
[Name]
Executive Director for Operations cc: SECY OGC ACRS GPA Regional Administrators 1-19
l i
EMiinill-4 (tenlinued)
DKhnuit h1cidenLhnc$ligalienlcaRLCbJultI Loss of Offsite Power and Failme of Onsite l'ower on Demand at Vogtle t! nit 1.
The scope of the llT investigation should include conditions precediH ' e event, event chronology, systems response, human factors considerations, equipmc aa for mance, j
precursors to the event, emergency response (NRC,4censee, and Feden and State agencies),
ufety significance, radiological considerations, and whether ;he regulatory process and activities precedirg the event contributed to it. Within the framework of this scope tne llT should specifically:
(1)
With rt5pret to tendhief oIestdingjhe_cycnt; livaluate :.he activities anJ plans which established the ini.:.o plant conditions. Identify the initial plant conditions (prior to s'vi of the transient). Identify whether the conditions were prudent and proper. Facts should be obtained regarding the licensee's actions associated with providing assurance of adequate 1(llR cooling during the outage activitin, including planning and coordination of equipment outages, emergency responses to mid !aop operational events, and review of applicable NRC reneric communications. Identify any procedural requirements and/c; deficiencies asse-ciated with the fuel tru;L s movement in the protected iuea.
0)
With respect to even'.tbronology: Develop and validate a detailed se<1uence of events associated with the loss of all AC power transient on tinit 1. listablish the cause of the Unit 2 trip.
(3)
Kiihaespect to emergencylc3peme; Develop and validate a detailed sequence of events associated with implementation of the emergency plan implementing procedures, including problems associated with the !!NN and liRF computer.
(4)
With respect to systems fcipenst; !! valuate the response of the 1 A liDG, including equipment performance (blacLout sequencer and jacket water pres-sure). Determine whether the Unit 1 switchyard breater actuations were appropriate and expected.
(5)
With r.ciptcLle_lu'nlan_fittle1LcensidealienM livaluate personnel performance including local 0;>:r sr actions in response to the l A liDG failure to start. With respect to safety st ficance of the event: livaluate ihe potential for long term core damage due to
's transient. Include the responses of operations and main-tenance personnel, RCS heatup, and potential containment challenges. livaluate the potential for a truck fuel con 0agration in this scenario and whether 'itness for duty rule was complied with.
I i
1-20
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I i
Ihhiblt 14,_(cpjllinued)
L (6)
Withfr>PetilfLthuerdaMLEtEen.and netivilirniateding ihe ntnu livaluate the adequacy of plant Technical Specifications for safety system oper-ability / availability during refueling nr. ode and any isnplications to other nnles.
I The scope of the investigation does not include: 1) assessing violations of NitC rules and i -
requirements; and 2) reviewing the design and licensing bases for the facility, except as necessary to assess the cause for the event under investigation.
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lhhibit 15 NilC3cg!0!LLMDbildendtittwlivrfvalualien I abulate1y The NRC Mobile Nondestructive laboratory is a fully equipped trailer capable of performing a broad spectrum of analyses. It is manned by a qualified NDil lxvel 111 NRC inspector and two technicians also qualified to at least txvel 11 in the basic NDli techniques of radiography, ultrasonic, magnetic particle and liquid penetrant testing. The NRC inspectols are qualified wcld inspectors. They are supplemented by two contractor personnel who are also qualiGed to the basic techniques of NDli and also provide the radiographic sources.
T,)e NDI! crew can be dispatched to the site without the trailer if consultation is needed or only limited inspection equipment is required for the test. The routine inspections performed by the NDE Mobile laboratory include pre service and inservice inspection, modification installation and fabrication, a> built configuration veriGeation of piping systems and mechanical components, and wcld qualification and proecss control. Listed below are the inspection capabilities of the Region i NDli Mobile I.aboratory:
(1) 1(adiegtwhy The laboratory is equipped with complete dark nwn facilities, isotope storage area, and facilities to perform and interpret radiographic examination of licensee inspection procedures or applicable codes, specifications and standards.
(2) 1.llinlie!1!C The laboratory has six in) ultrasonie units. These instruments are portable battery-operated capM k of perforuing manual examination of weldtd components at a nuclear facility (with accessories).
(3) 31tidmeEGwge portable battery-operated instrument, digital readout and automatic data lorging for measuring metal thicknesses wi'h the range of.050" to 10".
(4)
LiqttitLl' enc 1Eant Equipment to perform visible solvent remova'le and Horescent penetrant testing.
(5)
Wgnelicattlicle liquipmeat to perform (ac) yoke and ide) proJ magnetic particle examination.
O l-22
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[
ihhibit 1-5 (continued) 1 (6) llaidDns I
Portable battery-operated instrument for measuring hardness of material which l
can then be converted to lirinell or llockwell t,tandards and approximate tensile j
strength.
(7)
Dble Tracer Portable, battery operated instrument for h> eating and tracing electrical cables.
i (8)
EgilallkaLhnbc i
Portable, battery operatec nstrument for reading temperatures during welding, post weld heat treat, etc.
- (9)
Wgital MultimetcI l
- Portable, battery-operated instrument for measuring volts, ohms, and amps of 1
electronic circuits.
I t
(10)
- AMP Probe Kit Instrument used for checking line voltage and amperage, i.e., welding and l
magnetic particle currents.
I'1)
Shore Dorometri j
Used to check hardness of rubber products.
.j (12)
Mitital finnd Torque Wrench Digital readout hand torque wrench for static torque measurements with accuracy l
and readability. A large LiiD digital display along with digital peak memory to make static torque measurements, j
t (13)
Whidsor Preb.e (Swi3tilammeil f
I Jsed to determine the compressive strength of concrete, (14)
Infrared ThermomelcI Used for remote observation of materials temperature.
i 1;
i-1-23 j
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t E3hihiLld_1centhwn!)
(15)
SmfactCelupa!aten Used to de:termine average surface finish of metals.
l (16)
Menger..O!NS_0ereMet Iland cranted unit for measuring oluns resistance of items.
1 (l7)
Eenittjud!caleLLStreiniialite)
A desiee used for indicating the ferrite content of austenitie strinless steel weld inetals.
(18)
Netter:DidLCuno1Nachiet i
I l'ottable, battery-operated unit used for measuring paint thickness defects, i
(19)
I k M tici I
l'ortable, battery operated instrument for locating rebar embedded in concrete.
(20)
RMll'liotelachemtter Portable, battery-operated instrument used remotely, to determine motor Ill'Ms.
such as pump shaft speed, (21) l'jha!jen.Mcitt Portable, battery-operated instrument for measuring acceleration, velocity, and displacement of motors.
Instrument used to amine remote and hard to get to areas, such as inside pipe sur face.
(23) blU M f.1Edic1!el Portable, battery-operated instrument used to measure suiface finishes of i
i machined materials.
O 1-24 4
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i pq Allov AnalyIII i
Portable, battery-o[wrated instrument designed for rapid non-destructive onsite I
verification of type and element composition of many different engineering l
j alloys.
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Dhucusional Aids f
vernier calipers f
forma gauge l
micrometers l
slope angle indicators l
various coating thickness measuring devices t
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inhibit 16 AgtetaltalE!LWairrLP LCcWPtnsatienu.C2D tlicliff.lulcn!)
audl!clenteLinresliptintLinfenuatieli.ftt leduttrLJlcplescat alittLl'ulit ratintin i
incidenLl!1Ythticalirit 'lhun5.illTM
! anierstand that NI(C has solicited the participation of industry in connection with its incident investigation of lb'ame of Faci. lily). I have been requested by my employer lh'mutui empleynj to participate in NI(C's 11r investigation of such incident. I understand that my personal participation has been requested by iny employer and not at the specine request of the federal government. I intend to offer the NI(C team leader my best effort concerning such aspects of the investigation as I may participate in, but that I am under no obligation to the federal government to do so.
I agree that any services which I render to or for the benent of the government, pursuant to the agreement between NitC and INpo concerning IITs, shall be gratuitous, and I waive any claim for payment or compensation from the Government of any kind. I understand ' hat I will not be an employee of the government as a result of any service which I may render under the auspices of the agreement between N1(C and INpO.
I agree that I will abide by the guidelines and prmedules estallished for the operation of IITs, including the guidelines for handling differences of opinion an j release of investigation information. I understand that my input to the llT will be sub,cet to review by other team members and the llT leader, and that differences of opinion will either be resolved or documented in an appendix to the llT report, I understand that the team leader is to decide on the release of investigation information to parties outside the team.
With respect to proprietary and potentially proprietary information that is disclosed to me in connection with my participation in any llT, I agree:
not to make further disclosures not to make further copies to return my copies to the team leader or otherwise dispose of them as directed by the team leader upon completion of the investigation not to make further disclosures of copies of investigation or other notes that contain potentially proprietary information to report to the N1(C llT leader any uses of information which do not comply with this statement 1 26
lithihlL1-ILlenthltiedi to consult with the team leader before taking any action if I have any doubt or question as to whether it would be in accordance with this agreement Although I am not acting as a government employee or a special government employee or as a government contractor in my participation with the llT, I understand the importance of NRC avoiding the appearance of conflict of interest in connection with my participation with the llT. Accordingly, with respect to conflicts of inscrest, I make the following representations:
(Check one statement under each nun.ber) 1.
()
Neither 1 nor any member of my household has had direct previous invo;vement with the facility that I will be reviewing.
()
I or a membe* of my household has had direct previous insolvement with the facility that I will be reviewing. If you checked this statement, please explain.
2.
()
Neither i nor any member of my household is now or has presiously been an employee or contractor of the licensee or has otherwise received compensation from the licensee.
()
I or a member of my household is now or has previously been an employee or contractor of the licensee or has otherwise received compensation from the licensee, if you checked this statemerit, please explain.
. _ =
4 1-27
O Exhibit 1-6 (cenO1WCO 3.
()
Neither I nor any inember of my household is now or has previously been an owner, partner, trustee, officer or director of the licensee.
()
1 or a member of my household is now or has previously been an owner, partner, trustee, officer or director of the licensee. If you checked this statement, please explain.
4.
()
Neither ! nor any member of my household has any arrangement for, or is negotiating for, future employment by the licensee or for any future financial or official relationship with the licensee
()
I or another member of my household has an arrangement for, or is negotiating for, future employment by the licensee or for a future fmancial or official relationship with the licensee. If you checked this statement, please explain.
5
()
Neither i nor any other member of n 'iousehold owns or controls stock, bonds, or other sect,..iy interests of the licensee.
()
I or another member of my household owns or controls stock, bonds, or other security interests of the licensee. If you checked this statement, please explain. Your explanation should include J
the current market value of the securities.
l-28
t i
lhhlbit 1-6 (continuest) 6.
()
To my knowledge, I do not have any relative who is employed by the licensee in a management capacity.
()
I have a relative who is employed by the licensee in a managcment capacity, if you checked this statement, please i
explain.
7.
()
To my knowledge, the licensee is not owned or controlled by, and does not own or control, any entity of which I am currently an employee, contractor, owner, partncr, trustee, officer or i
director.
()
The licensee is owned or controlled by, or owns or controls, an O
entity of which I am currently an employee, contractor, owner, partner, trustee, officer or director. If you checked this statement, please explain.
?
[
In the above statements, the term " licensee" means the licensee, the architect engineer or the
~
nuclear steam supply system vendor of the facility where the incident under investigation has '
taken place.
In the event that a potential for a conflict _ of interest develops during the course of this incident investigation, I will immediately report all relevant information to the incident investigation team leader.
Name (please print)
Signature Date l 29
lithibit 1-7 EDO_ hit!Lletiwdtup on WairrLof Comrtthilen Poli yrt t
ArcidancteLQ1ganizationalCendicts of Irltrips fELinduilly_l'aIljcipaltts MEMORANDUM Foll:
Chairman [Name]
Commissioner [Name]
Commissioner [Name]
Commisdoner [Name]
FROM:
[Name]
lixecutive Director for Operations SUlllECT:
WAIVI!R OF COMMISSION POLICY ON AVOIDANCE OF ORGANIZATIONAL, CONFl.lCTS OF INTliREST FOR IN-DUSTRY PARTICIPANTS ON [11CILIIX] INCIDENT INVliST!GATION TEAM lt is the policy of the Nuclear Regulatory Commission (NRC), in accordance with Section 170A of the Atomic Energy Act, to avoid organinttional con 0icts ofinterest. Consequently, the NRC normally would not enter into a relationship where one of the participants would be placed in a position where its fudgment might be biased or where it might receive an unfair competitive advantage. This policy may be waived, however, in situations where the work cannot be performed except by a party whose interests give rise to a question of con 0ict of interest and where administrative and/or technical controls can be employed by the NRC to neutralize the conflict.
The NRC has decided to solicit the participation of [NatacLu.cf_ inh 31ry_ personnel _ arid affiliated _qrganization) on [Same of facility] NRC Incident investigation Teams (llT). INp0 acts as contact with NRC to nominate an industry representative. The objective of the llT is to perform a thorough factual investigation of signi0 cant operational events at NRC licensed facilities and to collect, analyze, and document factual information and evidence sut0cient to determine the probable causes of these events. The reasons for soliciting industry participation on the [Narpe of facility] !!T is to obtain an independent point of view on technical issues, and to facilitate the feedback of information to the industry for the self-initiation of potential preventative and/or corrective measures. The outcome of any given llT could possibly have a direct impact on preventative and/or corrective measures recommended to or imposed upon the industry by the NRC. The participation of industry personnel in an IIT would normally be precluded under the Commission's policy because of the potential self-interest of the industry in the outcome of an llT. The NRC believes, however, that the participation ofindustry representatives is essential to achieve the objectives for which the participation is solicited and to the accomplishment of the overall goals of the incident investigation Program.
1-30
I i
i Exhibit 17 (continued)
I The Commissioners 1 A number of controls have been established to preclude the introduction of bias into any incident investigation and to assure protection of the government's interest. Industry participants will be carefully screened to avoid any possibility of personal conflicts of interest resulting from such things as fmancial interest in the owner of the facility being investigated, previous involvement in the design or operation of the facility being investigated, and the like, Also, the technical product of the industry participants will be subject to review and criticism 4
by other members of the team, including the llT leader, as well as by NRC management.
The Director,' AEOD has recommended that the Commission's Policy on Avoidance of i
Organizational Conflicts of Interest be waived to avoid any questions that might arise under that policy concerning the participation of industry representative (s) on the [Name of facility]
llTs. Such a waiver documents the fact that NRC management has made a conscious decision in balancing the risks of allegations of biased input into the llT against the benents from industry participation. Ilased on the foregoing and after consultation with the Office of i
General Counsel, I make the following determinations:
The activities to be performed by the llT are vital to the NRC mission.
The participation of industry personnel on the llT is essential to achieve the objectives for which that participation is solicited and to the success of the overall goals of the Incident investigation Program.
Technical and administrative controls will be employed to neutrallre the conflict ofinterest posed by the participation of industry personnel on the team.
It is in the best interest of the United States to waive the Commission's Policy.
on Avoidance of Organizational Conniets of Interest.
Pursuant to the waiver provision specified in 41 CFR 20-1.54 " Contractor Organizational Conflicts cf Interest," the Commission's Policy on Avoidance Organizational Conflicts of Interest is hereby waived for the purposes of allowing the participation of IName(s) of industry l
oersonnel and affiliated organizalica] on the IName of facilityl NRC incident Investigation Team and for IName of engleyn] with respect to such participation by [Name of industry participim0,
[Name)
Executive Director for Operations 1-31
4 l
l 1
.I O
lhhibit 18
]kgipfLAtlien ltem Checklist For Arlinting_arLllI i
ACTION 1.
Consult with the Directors of Nillt or NMSS and AEOD to consider weather an llT is l
appropriate.
1 l
2.
Make recommendation to !!DO.
1 3.
Issue Confirmatory Action Letter (CAL).
l 4.
Designate a regional representative to interface with the llT.
5.
Briefing package prepared and available for the llT upon site arrival (Exhibit 1-3).
6.
Consider the need for a Public Affairs Officer onsite.
7.
Negotiate with the licensee for sufficient office space for the llT.
A conference room for the team (preferably onsite)
At least 2 interview rooms Telephones (including conference call)
Area for administrative functions S.
Provide secretarial support.
9.
Arrange for site access for the !!T.
10.
Coordinate the entrance meeting and I.
site tour.
11.
Provide staff to monitor troubleshooting.
O' l-32
i i
GUIDELINI? 2: CONDUCTING AN INCIDliNT INVIGTIGATION 2.I htipcic j
Guideline 2 provides guidance for conducting an Incident Investigation Team (llT) investigation, j
i
2.2 Background
The objectives of the llT are to: (1) conduct a timely, thorough, systematie, and independent investigation of safety signincant ever ts that occur at facilities lleensed by NitC; (2) collect, analyze, and document the factual information and evidence sufficient to determine the l
probable causes, conditions, and circumstances pertaining to those events; and (3) determine whether the agtney actions taken prior to the event contributed to the cause or course of the -
event.
i To meet these objectives, the investigation includes four major activities: (1) collection of data and information; (2) analysis and integration of the facts; (3) determination of findmgs and conclusions; and (4) preparation and presentation of the team's report.
These guidelines are intended to assist the investigation rather than limit the initiative and good judgment of the llT leader or members; they should use their experience and those i
techniques that provide the most confidence in assuring that ilT objectives are achieved.
A detailed team charter delineating the scope of the investigation will be provided to the llT leader. Further details on the investigation scope art provided in Section 1.5 of Guideline 1.
2,3 IIT lodcLRQnonsibilitics The IIT leader manages the investigation and delegates responsibilities to NitC team members and to assigned C1cc for Analysis of Events and Operational Data (Al!OD) staff. Check lists for conducting the investigation are provided in Exhibit 21. Specific responsibilities include:
- (1)
Directing and managing the llT in its investigation and assuring that the objective and l
schedules are met for the investigation, as denned in NitC Manual Chapter 0513.
(2)
Identifying, adding and removing equipment from tlic quarantined equipment list (QEL) within the constraints of ensuring plant safety and determining causes for equipment anomalies (see Guideline 4).
21
(3)
Serving as principal $;mkesperson for the llT and the joint of contact for interaction with the licensee, NRC of6ces, Advisory Committee on Reactor Safeguards (ACRS),
news media, and other organizations on matters involving the investigation.
(4)
Coordinating activities with the Director, AEOD, as necessary, to obtain ad-ministrative support and/or advice and consultati(1 on procedural matters involving the investigation.
($)
Preparing preliminary no ' cation (PNs) and other status reports documenting IIT activities, plans, signincant findings, and safety concerns that may icquite prompt NRC action, e.g., issuance of Information Notices, llulletins, or Orders.
(6)
Organli.ing IIT work, including the establishment of schedules, plans, wolk tasks, daily team meetings, etc.
(7)
Assigning tasks to NRC team members in accordance with their knowledge, es-perience, and capabilities. The llT leader will identify assign.nents for the industry representative team members.
(8)
Not permitting NRC team members to dilute their investigative commitments with any other work assignments: their sole work activity should be limited to the incident investigation until the report is published.
(9)
Administering resources provided and obtaining resources needed to properly carry out all necessary investigative tasks (e.g., obtaining additional team members, consultants, contractor assistance).
(10)
Ensuring that investigative activities do not unnecessarily interfere with plant activities.
~
(11)
Initiating requests for info mation. witnesses, technical specialists, laboratory tests, and administrative support.
(12)
Controlling proprietary, safeguards and other sensitise information to *need to know" and cleared personnel.
(13)
Handling communications with NRC headquarters and regional officials (designated representative).
(14)
Informing the Executive Director for Operations (EDO), through the Director, AEOD, of all significant findings, developments, and investigative progress. Request that the EDO grant an appropriate extension of time if established deadlines cannot be met.
(15)
Consulting freque niy with IIT members to ensure a team approach to the investigation in matters such a:.evising the report outline, assigning member responsibilities, 2-2
i discussing the list of items that should be closed out before leaving the site, identifying investigatory milestones, and seeking consensas on the contents and relevant informa-tion to include in status and Gnal reports.
(16)
Ensuring, in cooperation with the teiun members and the technical writer / editor, the preparation of the final report within the due date established by the EDO.
(17)
Ensuring that frequent and successful communications occur among the AIT, llT, and the licensee during the conversion to ensure an orderly transition in the event that the investigation is either upgraded or downgraded (See Guideline 1).
(18)
Ensuring that the following activities are completed prior to the end of the onsite portion of the investigation:
a plant tour and thorough inspection of affected equipment all onsite interviews development of a detailed sequence of events review and approval of the quarantined equiptnent list and corresponding troubleshooting action plans (TAPS) arrangements with regional perso%el for the monitoring of component troubleshooting activities 2.4 Itole of thc.lknien.inAPMLcLihdenduct of thclncidentinualitalien The responsibilities of the itegion during the conduct of an llT investigation are to: (1) assist in brie 6ng and providing background information to the llT when it arrives onsite, (2) provide onsite support for the llT, and (3) identify and provide staff to monitor licensee troubleshooting activities to assess equipment performance. The Regional Administrator she ' designate a regional representative to interface with the llT. The regional representative <,hoald attend most meetings between the llT and the licensee. The responsibilities of the llegion during IIT activation are provided in Guideline 1, Section 1.8.
2.5 laitiaLAttiendy_.thclElcader (1)
Prior to arriving onsite, the llT leader should introduce the team members, brief the team on the event, on the scope of the investigation, and on how the team will func-tion, in addition, the llT !cader should verify that all industry representatives have signed a statement (Exhibit 16 of Guideline 1) regarding their participation in the llT.
During this briefing, the llT leader should assign each team member a speciGe area of 2-3
responsibility, e l'., compiling the sequence of events, examining equipment performance, determining the human factors issues.
(2)
U;wn arriving at the site, the llT leader should give priority attention to: (a) initiating a meeting with tN licensee to learn what is known about the event and to reach an understanding with the licensee about the llT's activities; (b) scheduling interviews with personnel having a direct knowledge of the event; (c) developing a detailed sequence of events; (d) compiling a Q1!L and TAl's; and (e) responding to press inquiries. Guidance for conducting press releases is contained in thhibit 2 2.
]
(3)
The llT leader should t isure that arrangements have been made for those items requiring licensee assistance. These could include:
Scheduling an entrance meeting with licensee management as soon as practical to discuss the event and the llT investigation, and arranging for a meeting hieation in advance to allow sufficient time for stenographers to prepare to transcribe the meeting.
Scheduling a tour of the plant to begin immediately after the entrance meeting to inspect the affected systems and equipment and to gain familiarity with the plant.
Determining if the licensee wishes to provide photographic services during the investigation.
Identifying individuals with personal kr
!cdge of the event and establishing a preliminary schedule for mterv ew:;.
Reviewing the preliminary list (complied by the ficcasee) of til failed e
eqmpment and any equipment suspected of performing abnormally during the event; this list constitutes the initial Qi!L to be discussed during the entrance inecting.
(4)
AEOD staff will accompany and provide technical and administrative support to the llT. The llT leader should verify the extent of administrative support provided by the Region, e.g., background documents, secretarial support, regional liaison. Such support could include:
providing a briefmg package for the team (see Guideline 1, lhhibit 1-3) obtaining a meeting room to conduct llT meetings and daily business O
2-4
1 l
l O
Identifying and distributing telephone numbers and site locations to estabhsh conununications for the llT confirming that the room (s) for conducting personnel interviews are available as previously requested by AEOD obtaining unescorted access to the protected area for llT personnel, however, if time does not permit the completion of training for unescorted access, the llT leader r.hould arrange to obtain escorted access 2.6 Entrance hicc11c; with theJJtrace The objectiv'
'the entrance mecung are to: (1) establish a rapport with and enlis' the cooperation...ne licensee, (2) discuss the purpose and scope of the llT investigation, (3) obtain the licensee's understanding of what occurred and why it occurred, and (4) toquest assistance frorn the licensee in obtaining information and resources. The following activities take place during the entrance meeting G
(1)_
The llT leader will be the lead spokesperson fo', zne NRC and will be responsible for directing the meeting and ensuring that all tbo major objectives of the meeting are Covered.
g (2)
The stenographers must receive accurate information regarding the names of those speaking, their job titles, and their ernployers.
(3)
An attendance sheet should be circulated among those present at the meeting.
(4)
The llT leader should make an opening statement similar to the following:
The purposes of the incident investigation are to establish what happened, to identify the probable causes, and to docume:it our findmgs and conclusions and issue a report within about 45 days. We will also be issuing statur. reports to our headquarters to keep them informed on the progress of our investigation, The investigation is not a reanalysis of the plant design, nor is it a compliance inspection, although our report can be used to form the basis for enforcement actions. We request that any information available as a result of your er other
. investigations be shared with us.
There are several things we would til.e to accomplish at this meeting. First, we want to get up to speed on your understanding of what occurred and your a
hypothesis of why it occurred. Second, we would like to establish our O
interfaces for the investigation where we can seek technical information er ask
-(
for assistance such as escorts or looking at any particular pieces of technical 2-5 t
documentation or equipment involved in the event. Finally, we would like to review with you our investigation process which includes interviews, the trouHeshooting of quarantir.ed equipment, the handling of press inquiries, and the exchanging of information be'wcen your staff and the team. That is our agenda for this meeting.
(5)
Licensee personnel should be al; owed to describe what happened with few interruptions The team should tl en identify additional penonnel for interviews and followup topics to evaluate.
(6)
The llT leader should request that the licensee post a notice on all plant bulletin boards and inajor points ofingress and egress describ;ng the purpose of the llT investigation and soliciting information regarding the event (thhibit 2-3). This posting should also be made at any offsite hieu. ions that might be involved in the incident.
(7)
The llT leader should review with the licensee the preliminary list of failed (quipment and equipment suspec'ed of performing abnormally Jaring the event. This list con-statutes the initial quarantined.%aipment list (Qlil.). The QliL should tie maintained by the licensee and be as curre it and complete as possible and should pencrally include o#y eculpa ent significantly involved in the event that failed to perform its intended function.
(8)
The llT letder shoald conSrm with ihe licensee that equipment on the QliL will be clearly identified and sesured, and that no maintenance / testing will be initiated nntil the action plan for each component is reviewed and approved by the team. The llT tcadcr should ;ndicate that the licensee can take any action involving the QlIL necess:uy to: achic*e or maintain safe plant conditions, prevent further equipment degrmiation, or conduet testing or inspection nctivities required by the plant's Technical Specifications. To the degree passib!c, these actions should be coordinated witn the llT leader in advance or notification made as soon as practical afterward.
(9)
The IIT leader should reouest that the licensee pro,ide a preliminary sequence of events and upcate it as addhional information and data become available.
(10)
The llT should review with the licensee all aspects of the llT investigation process, including interviews, the troubleshootmg of quarantined equipment, the handling of press inquirics, and the exchange of informatJon between the ilT and the licensee.
(11)
The 117 should request thx, copies of a!! doemmnts requested by the tearn (e.g., the cornputer sequence of events or data logging, relevant procedures, operating instructions, detailed plant design information) be sent to a designated receiving office.
S 241
)
l (12)
The llT should provide the licensee with a copy of Guideline 4: Treatment of 2
Quarantined ikluipment and thhitil 31, ' Guidelines for Review and Availability of l
Transcripts."
j (13)
The llT leader should request that the licensee establish a liaison for communications l
with the llT.
i 2.7 l'lant Imitaf.M(csici.!!Qtlipantnutnd.Syncms The inspection of plant equipment and systems involved in the event and other relevant plant facilities (e.g., control room) abould be scheduled after the entrance meeting and prior to personnel interviews. During the plant tour, preliminary observations, luues and considera-l tions should be written down as a basis for questions to ask of licensee personnel during 1
interviews, t:
Although the llT will be provided with the necessary equipment to have photographic i
capability, if the lleensee wishes to provide this service, it should be given the opportunity to do so during tne investigation. Photographs of equipment should contain something of known size (a ruler, hand, or person) to show the relative size of the object photographed.
Consideration should be given to the use of some black ar.d white photographs for reproduction in the report.
i
\\
The photographer sh add maintain a log that indicates the subject of each photograph. Each photograph should be assigned a number and include a brief description of the subject. The i
regional representative may be available to assist in identifying information for the photographer, 2.8 Interviewing Personnel Following the plant tour, the llT should begin the interviews with the most senior individual with direct personal knowledge of the event. Individuals initially interviewed onsite often include: eOntrol room operators, the shift technical advisor, plant /cquipment opentors, security personnel, site managenet, corporate personnel, health physicists, technicians, i
casual observers / witnesses, NRC resident inspectors, and local officials and residents if appro-t priate, Later in the investigation, when attention is turned to the evaluation of pre-existing conditions or about how agency actions taken may have contributed to the event, additional-interviews of licensee or NRC staff may be necessary. The interviews of licensee management personnel are intended to understand the context and priority of actions which were or were not taken. For guidance on conducting interviews refer to Guideline 3.
2.9 Srqucass.20htals
[
The llT should compile a detailed sequence of events based on the one provided by the
(
licentee, on informulon obtained during interviews, and on material specified below and -
2-7 a
u
review it with the licensee. The sequence of esents is one of the llT's most imoortant collection of data and must be factu'd. Exhibit 2-4 contains a sample sequence of events.
The llT should consider, resolve, and integrate rekvant information and data. Such information could include:
the licensee's sequence of event,
the output from the plant's data loj'ging systems eperators' plant logbooks and control room instrumentation records (i.e., strip c' arts)
[vrsonnel observations from interviews i
The sources of information identifying an event for the sequence of events should be documented for future reference. Areas of uncertainty and contradictory information should be pursued and resolved by methods such as additional interviews, submittal of wi' ten questions to the licensee, or additional analyses of available information.
The llT's initial sequence of events compi!ation should be issued in a Preliminary Notifica-tion (PN) within 3 to 5 days after arriving on site (Eshibit 2-5). Prior to issuing the PN, the IIT leader should review the sequence of events with the licensee.
2.10 OuarantinesLEquipment.. List (OEllanlLImubkShDD1iDIArdnafanLffAl'9 For specific guidance on the QEL and TAPS, refer to Guideline 4. As noted previously in section 2.6, item 8, agreements should be reached during the entrance meeting on the preliminary QEL and the fact that troubleshooting maintenance should not begin prior to llT approval of TAPS. The statu., of equipment on the QEL should be updated and revised based upon the sequence of events, personnel interviews, data reviews, etc. The regional or resident's office should be requested to help monitor this equipment and the implementation of the TAPS.
- 2. I 1 llT_Cenlinationliccliots Periodic progress review meetings are an important coordinating technique for the llT leader and a way of keeping the licensee and team members current with the progress of team activities. The team should meet at the end of each day to review results obtained by all team members and to plan the team's activities for the following day. The llT leader should meet with the licensee on a daily basis to discuss the team's activities.
9 2-8
i 2.12 Slainllrpstt f
The llT should prepare and issue a Preliminary Notification (pN) Report at the end of the tirst day of the investigation. The PN will be prepared by the llT onsite tnd transmitted to r
AEOD for distribution. The PN should provide a brief description of the event, current plant status, current licensee and IIT activities, and the names and phone numbers of IIT contacts.
In general, the llT leader and assistant itT leader will serve as llT contacts during the investigation. A sample PN is included in Ihhibit 2 5. The PN number is PNO-ilT-(year).
(number of this llT this year)(letter identifying series of PNs). The llT should also issue subsequent PNs periodleally (every 2 to 4 days while on-site) to update llT activities for i
regional and headquarter offices.
When the sequence of events is well understood, the llT leader should suggest a conference call with the EDO, the Office of Nuclear Reactor Regulation (NRR) or the Orfice of Nuc! car Material Safety and Safeguards (NMSS), AEOD, and the Region to inform them of the i
team's information and to respond to their questions. If in the course of the investigation i
signineant new information is identified, the llT leader should promptly inform the EDO by telephone.
2.13 - collection of Information and liceordkeeping.Actirilies All information obtained by team members will be brought to the attention of the llT leader, Industry representatives may orally discuss veritied factual event-related information to nuclear industry organizations with the approval of the llT leader. This information should
-be transmitted only for purposes of prevention, remedial action, or other similar reasons to ensure public health and safety. The industry representatives will keep the llT leader upprised of all information pertinent to the event. Common sense and good judgment must predominate in this matter.
^
All investigative interviews should follow Guideline 3, " Conducting Inten'lews." In general, a record will not be made of discussions between the team and licensee personnel about routine administrative matters.
An administrative assistant coordinator assigned to the llT investigation will be responsible for document control. It is important from the outset, however, to distinguish between "information reviewed" and information used to substantiate the sequence of events, team findings and conclusions, it is only the more significant latter category that aquires document control. The team members should ensure that al relevant documents are provided to the admir.istrative assistant coordinator for proper control and disposition. Documents containing sensitive information (e.g., proprietary, safeguards) will be appropriately identified by the licensee, properly marked on the outside cour, and stored in a safe or a locking file cabinet.
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2.34 lire 9pliD110_hr1Linqttitif3 A neu conferexe may be desirable. If so, it should be wheduled as soon as possilde aftet the arrival of the llT trader, The Regional Public Affairs Officer could be avail,ab'e onsite to arrante the e
news conference and be the point of contact for the news media. The Regional Public Affairs Officer, llT leader, and the licensee should coerdinate press conferences and responses to press inquiries, The llT leader will be the lead spokespesson for flT activities and should jimit discussions during and subsequcot to the news conference to the scope and purpose of the investigation, to the llT process, and to the team's sequence of events. Information provided to the press about the event should be identified as preliminary and subject to confirination.
If detennined necessary, in consultation with the Of6ce of Governtnental and Public Affairs, a headquarters or a regional representative will be available to participate in the news conference (see Exhibit 2 ?).
2.15 1sitttlifyint AddillenhpsninnLQmi&_Aniimmr The llT leader should assess the need for additional expertise, particularly during the initial phase of the investiption Obtaining additional NRC or contractor personnel should be considcred if certain aspects of the event are unique and beyond the expertise of existing team members, or if the scope or complexity of the event in sufficient to warrant additional superior staff.
NRC personnel are available to conduct nondestructive examinations (NDE) activities on a wide variety of equipment and components. A mobile NDE laboratory can be sent to the site if appropriate. NRC personnel are also available to conduct radiation surveys and analyses. See Exhibit 1-5 of Guide-line 1 for a description of NDE capabilities.
The llT leader shouki discuss requests for additional assistance with the Director, AEOD, who will make the necessary arrangements.
2,16 Lnflunry Participation in thrinxenigaften Induury representatives may participate as full-time members of the llT. They are expected to perform in the same manner as NRC team members and NRC will accord them the professional status and courtesy accorded NRC team members.
2-10
i r
I 2.17 Earallel Invesikallens Normally, the llT conducts the NRC's primary investigation of an event, consequently, it is
[
expected that other investigations, by the licensee or by industry will be conducted in ways that do not interfere with the llT. Should the team's activities be impeded, delayed or limited l
tvecause of puallel investigations, the llT leader should try to reso'tve the problem with the
~
4 licensee and/or appropriate organization. If attempts fail or the situation is not resolved to the t,atitfaction of the llT leader, the llT leader should immediately bring the situation to the E
attention of the Director AEOD, who will coordinate the agency response to the situation with the EDO, Office of the General Counxl (OGC), Regional Administrator, and other NRC ofnees.
In instances where a.related investigation is being conducted by another NRC office, such as the Of0cc of Investigation (01) or the Office of the Inspector General (10), coordination between the two investigative bodies, and between AEOD and the respective NRC ofGee should be established to avoid hindering the efforts of either investigation.
l If the Institute of Nuclear Power Operations (INPO) is developing a Significant Event Report (SER) on the event, they will attempt to ensure that the SER is consistent with the facts of the i,
event as understood by the llT. This will be accomplished by INPO providing a draft of the SER to the licensee prior to issuance. The licensee will coordinate review of the Sf!R with j
the llT, and will ensure any inconsistencies are made known to INPO so they can be resolved prior to issuance of the SER by INPO.
2.18 Rfferral of Inve.stigation Information to NRC Offices During an llT imestigallon, the team may learn directly of allegations, potential wrongdo.ing or information that should be referred to other organizations for followup and disposition.
The !!T leader has the responsibility to identify situations warranting referral and to make the t
appropriate notincations when referral is appropriate Guidelines regarding referral of 1
information to O! or IG are contained in NRC Manual Chapters 0517 and 0702. The regional representative should be able to assist the llT leader in making the appropriate notifications.
2.19 Confidentiglity The NRC's inspection and investigatory programs rely primarily ou individuals voluntarily providing accurate information. Some individuals, however, may agree to provide needed information only if they believe their ldentitic; will be protected from public disclosum. In cases where the llT leader believes that needed information wi!! only be obtained by providing assurance t_ hat the NRC will not identify the individual, the IIT leader should contact the Director, AEOD, who will coordinate the situation with the EDO, OGC, and the Regional Administrator.
P 2-11
2.20 Subtvena Power and_Pqntr_teAdminshOdihaniMdunal!23 Subpoena power is available to the NitC to assist it in gathering information whiet is related to the agency public heal:h and safety mission. Most investigations conducted are accomplished without the need for a compulsory process because most inteniews and iniormation are given voluntarily. Consequently, whenever information is considered to be vital to the investigation, and the individual or entity refuses to either i e interviewed or provide documentary information, the !!T leader should immediately bring the situation to the attention of the Director, AEOD, who will coordinate the agency response to the situation with the EDO, OGC, and the itegional Administrator in general, oaths are administered to ensure that individuals interviewed properly recognize the gravity of the situation. The point at which an oath is administered depends on the circumstances surround'ng the interview. When a situation nrises where the adminntering of an oath is seriously being considered, the llT leader should conta t the Director, AEOD, who will coordinate the situation.
2.21 hiunLSht.Yji!!
The team should consider scheduling a return site visit Oypically about 4 weeks after the event) to review any significant findings from the licensee's investigation, particularly from the troubleshooting activities conducted on quarantined equipment.
2.22 hporLPRouation and PreXHtalien An outline of the report should be developed before the conclusion of the onsite investigation and assignments made of specific sections to team members. This phase of the investigation is addressed by an Guideline 5: lleport Preparation, which includes a detailed schedule.
Each team member will participate in a comp!cte review of the team's investigative report for technical accuracy and adequacy in his/her particular area of technical expertise. The llT leader will obtain each team member's concurrence on the report signifying that the team member has reviewed the report and that any differences of professional opinion have either beer, resolved or documented in an appendix to the report. Copies of the llT's final report will be provided to the participating team members.
The llT leader will be expected to orally brief the EDO about the report within about 40 days, with the advance copy of the report sent to the EDO and the Commission within about 45 days. Fo!!owing issuance of the advance copy, the team will normally brief the Commission in an open meeting and subsequently the ACl(S on llT tindings and conclusions.
The team's report is also issued in final form as a NtmEG document.
O 2-12
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2.23 Ikhibits Ilxhibit 2-1 1IT Team lcatrLChrddbi Ieam trader Initial Acticas:
1.
Ilrief team members on the event, scope of the investigation, and auignments 2.
Verify that all industry representatives have signed waivers (Exhibit 1-2) 3.
Conduct entrance meeting use stenographers to transciibe meeting request lictnsee to post IIT notice (lixhibit 2 2) review prelindnary QlII. (Guideline 4) pg request preliminary sequence of events o
Q review all aspects of IIT provide the licensee with copics of IIT riuideline 4 and Exhibit 31 of Guideline 3 cstablish an agreement for treatment of quarantined equipment 4.
Schedule news conference (if desired)
(Guideline 2, Section 2.14) 5.
Schedule Interviews (Guideline 3) 6.
Establish quarantined equipment list (Guideline 4) 7.
Arrange for photographic services (preferably the licensce's; see Guideline 2, Section 2.7) 8.
Verify the adequacy of administrative support and request additional support as needed t
(
2-13
l EthihiL2_L(centinite10 llLIranticadeLChedJitt Onsite invcitigalien 1.
Perform plant tour (Guideline 2. Section 2.7) 2.
Issue PN at the end of the Grst day (Guideline 2, Section 2.12) 3.
Compile sequence of events (Guideline 2, lhhibit 2-3) 4.
Conference call (AEOD/Nitil/NMSS as applicable) to discuss sequence of events 3.
Issue PN with sequence of events (3-5 days) 6.
Complete interviews of all individuals having a direct knowledge of the event 7.
Complete reviews of troubleshooting action plans and implementation schedule (Guideline 4) 8.
Arrange for Regional personnel to monitor the implementation of troubleshooting action plans 5
9.
Schedule a return site visit (if desired) 10.
Develop a report outline (prior to leaving site)
(Guideline 5, Section 5.4)
O 2 14
lithibit 2 2 hc15fenicIrJKLGu[dallCC Use talking twints ano fill in ihe details. The following areas should be considered:
Purimse for investigation lhplanation of.v. hat an llT is and frequency of use Plans and expected length of stay Scope of team expertise What has been determined litief nontechnical description of the incident (assume that information is already known) and put the event into perspective (danger to public and/or radiological releases)
Sequence of events (if known)
Current plant status Status of team activities and fmdings (if any)
Expected date fer re;xnt issuance Think of questions that you might get and preparc. Typical questions might include the following:
Why was an alert declared and what does this mean?
Was it an operator error?
Were regulations violated?
Was it a r. car miss?
llow does this compare to a previous event?
2-15
Exhibit 2-3 Generic Bulletin Board.Endice (Current Diue)
POST ON ALL BULLE'llN BLARDS TO:
SITE PERSONNEL
SUBJECT:
(Date of Event), (Event Description)
The subject incident is being investigated by an independent team of NRC perronnel. The purpose of the team is to establish what haopened, to identify the probable cause(s), and to provide appropriate feedback to the industry regarding the lessons learned from the incident.
Anyone having information or observations that relate to this event, and wishing to communicate this information to the investigating team may contact (llT leader) or (assistant IIT leader) at (phone number) or (phone number).
IIT Irader O
2-16
/~N Exhibit 2-4 Example llTJgluninary Sequence of Events Initial Plant Conditions; Unit 2 operating at steady state power of 100%.
Unit 1 in day 24 of a planned 44-day outage.
Non-emergency ac power was being supplied by backfeeding through the main transformer to the unit auxiliary transformers.
Power was being supplied to both emergency 4kV buses from a single transformer (the 1 A reserve auxilia7 transformer).
The other 4kV emergency transformer (the IB reserve auxiliary transformer) was out of service for planned maintenance.
_One of the two unit I diesel generators (IB) was out of service for overhaul and v/
inspection.
The."A" loop of residual heat removal (RhW) was providing core cooling with the reactor cwlant. system in mid-loop at approximately 90 degrees Fahrenheit.
The reactor coolant systen, was open at several locations for maintenance. The containment equipment hatch was fully open for removal of equipment.
The lB RHR injection valve was closed and out of wrvice leaving only the 1 A injection valve (which was de-energized open) availabic for shutdown cooling.
Time' Descriptic_n of Event 0920 A lubrication and fuel truck backed into a support post for the 2?'k me resulting in loss of power to the l A reserve auxiliary transformer supplying both Unit I and one of the Unit 2 emergency 4kV busses. This resulted in a trip of Onit 2, loss of ac power to the Unit i emegency busses, and an undervoltage start of the l A diesel generator.
0921 1 A diesel generator tripped -
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All times ce EST. Some previous reports of this incident were reported in CST.
2-17
O Exhibit 2-4 (continutt)i 0940 Site arca emergency declared due to loss of emergency ac power for greater than 15 minutes.
0941 Diesel generator l A restarted as expected when the load sequencer was locally reset. Diesel generator l A tripped again.
0956 Local emergency start of diesel generator l A was successful and emergency AC power was restored to the l A emergency bus, 0957 Emergency plan initial notiGeations of the Site Area Emergency (SAE) commenced.
0958 NRC Operations Center notified of SAE.
1000 RHR was restored. The maximum primr.ry coolant temperature reached 136 degrees Fahrenheit.
1013 Completed initial noti 6 cation of required off-site emergency response organizations except for Georgia Emergency hianagement Agency (GEh1A) and Burke Couc v Georgia. (The normal Emergency Notification Network (ENN) was out of service in the control room because it is powered by vital power which was lost.)
1015 The SAE was downgraded to an alert.
1016 GEhtA is aware of an emergency at Vogtle due to checkout of ENN from the Technical Support Center, but does not receive the details of the SAE.
1026 The plant Technical Support Center (TSC) was activated.
1029 The TSC informed GEh1A that the SAE existed but had been downgraded to an alert.
1034 Installation of the steam generator primary manways was completed.
1035 GEh1A received a facsimile from South Carolina with the details of the initial notification.
1041 initial formal notification of GENIA was completed by the licensee.
1042 The containment equipment hatch was bolted in place.
2-18
i 4
I L
- Exhibit 2-4 (continue <jj l:-
)
1140 The til emergency bus was re-energized from its normal transformer (reserve
..[
auxiliary transformer IE), which had been out of service for maintenance, i
l;
_1140 The pressurizer manway was in' stalled.
1238 RHR was shifted to the B RHR pump to facilitate later electrical alignment changes.
=
l' l-1347 Emergency terminated.
l l
1426 The 1 A diesel generator was shutdown. Both emergency busses were eceiving t
j power from the 1B reserve auxiliary transformer.
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O 2-19
O Exhibit 2-5 Example Preliminary Notification Reoort DATE: 11/26/85 PRE! IMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-llT-85-2B Th;s preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information presented is preliminary, requires further evaluation and is basically all that is known by the IIT on this date.
FACILITY: Southern California Edison Company Emergency Classi6 cation San Onofre Unit 1 X. Noti 6 cation of Docket No. 50-20 Unusual Event
_ Alert
_ Site Area Emergency
_ General Emergency
_Not Applicable
SUBJECT:
Status Report from NRC Incident Investigation Team The Incident Investigation Team (IIT) remains onsite gathering data, conducting interviews, inspecting equipment, inecting with the licensee, concurring in licensee action plans and analyzing W:t". A preliminary sequence of events nas been developed by the llT and is attached. A set of preliminary hypotheses explaining the significant events has been developed by the IIT and are being investigated.
All interviews should be completed on November 27,1985. All licensee action plans for further troubleshooting and uncovering remaining event related information should be fmalized on November 28,1985. Assuming the combination of information possessed by the IIT and the licensee action plans to uncover additional facts appear adequate to project closure of significant open issues, the IIT intends to depart the site by December 1,1985, and to reassemble in Bethesda, Maryland.
A final status report will be issued prior to the IIT's departure from the site, CONTACT: [IIT leader]
[ asst. IIT leader]
[ phone number]
[ phone number]
2-20
GUIDELINE 3: CONDUCTING INTERVIEWS 3,1 Purpose-Guideline 3 provides guidance to ensure inteniews are conducted in a uniform, systematic and complete manner, 3.2
. Background
e The information derived from a personnel interview is often directly proportional to the skill of the interviewer, Planning on the part of the interviewer is necessary to conduct the interview systematically, Predetermined questions concerning suspect areas should be asked of all inteniewees.
Prior to conducting interviews, the llT should have been briefed and given an escorted plant tour to obtain an understanding of what had occurred and to obtain a general working knowledge of the plant design and layout. Inteniews should be conducted as soon as possible after the entrance meeting and plant tour to minimize information lost over time from the memories of those involved.1-ligh priority should be given to inteniewing personnel on duty _at the time of the event to learn about the actions they took and the observations they made.
Most interviews are transcribed by a stenographer to ensure that an accurate record of the interview is obtained, and for the convenience of the Incident Investigation Team (IIT).- When the team writes its report, an accurate, factual record is available to determine the findings and to make conclusions regarding the event. The necessity for
-note taking is minimized during the interview, which also eliminates contradictory and erroneous information that can result from note taking. Team members can give their undivided attention to understanding the obseivations and actions of the inteiviewee
- during the event. Explanatory sketches, diagrams, photographs, or written statements are valuable supplements to the interviewee's statements; however, they should not be construed as substitutes for the narrative statement. In general, discussions between the
-LIT and licensee personnel about routine administrative matters and/or subsequent minor followup _ questions for clarification do not necessarily have to be transcribed. In those limited cases where the team leader deems it inappropriate to transcribe an
- interview (i.e., the presence of a stenographer would be detrimental to free flow of information), the team should conduct the interview as outlined in section 3.5 of this guidehne, taking detailed notes documenting the conversations between the team and
. inteniewee.
3.3 Scheduling and Team Attendann Interviews should be' scheduled, if possible, with personnel in decreasing order of
- g
, authority within the staff, An interview schedule should be prepared for each day. The i
schedule should include the interviewer's name, location, and start time of the interview, Generally, about 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> should be scheduled for each formal interview.
31
O Selection of IIT members that will actively participate as interviewers during the interview should be minimized, and based on team member assignments and technical expertise. A minimum of two 11D1cinbis should be present at all interviews.
A lead llT spokesperson should be appointed for each interview who is responsible for introducing the interviewee to llT members, allaying qualms, explaining and answering questions about the inteniew process, providing some background on the objective and scope of the llT investigation, and controlling the interview. The objective should be to establish an element of rapport.
3A Third Party Attendance Interviewees will normally be permitted at their request to have personal counsel m another individual accompany them during the interview, Otherwise, third parties, such as licensee management, company counsel, and union stewards, will not normally be permitted to attend the interviews.
The inteniewees may cons' 't the counsel during the interview. Counsel's participation in the interview will be gen..ily limited to advising his client and asking brief clarifying questions to ensure that his client has understood the questions asked by the llT. If the counsel or other individual also represents or is to accompany another person being interviewed, the llT will ~.ormally permit the attendance of that person if the llT is satisfied that attendance will not appreciably compromise its investigation.
The IIT normally will not permit tape recording of the interview by the interviewee since the interview will be transcribed and the intenne will be provided a copy of the transcript, if requested.
If the above policy regarding the rights of inteniewees is unclear and additional legal advice is necessary or desired, the IIT leader should contact the Assistant General Counsel for Enforcement in the Office of the General Counsel (OGC).
3.5 Interview Guidelines The following general guidelines should be followed for conducting interviews:
(1)
Prior to conducting the interview, the lead spokesperson should discuss with the interviewee the following:
'llie_pyrposes oflhe incident investintion Team are to establish what happened, to iGentify the probable causes, and to provide appropriate feedback to the industry regarding the lessons learned from the incident.
The reason for conductingjnterviews is to obtain information regarding the actions and observations of personnel who were directly involved with the event.
3-2
.IlttPmpose of transcribing _interviem is to aid the team in developing a factual record and as a convenience to minimize the amount of note taking.
The transcripts will be made autMle for review. The interviewee will have the opportunity to make corrections regarding where he/she feels that something was transcribed incorrectly or make clarifications to statements which were what was said, but not what was meant. The corrections and clarifications will be included as part of the transcript.
Transcriots will be madtntthlicly available in the NRC's public document room at the conclusion of the investigation and after the issuance of the team's report. At that time, if requested, a copy of the transcript will be provided to the interviewee.
lhird n;tnigs attend interviews only at the request of the interviewee. The interviewee will be asked whether he/she has requested the presence of any third party attending the interview. If the third party has attended or will likely attend other interviews and/or will represent others (e.g., the licensee), the team should establish that the interviewee is aware of this fact and nontheless desires the third party's attendance.
(2)
The interview should begin by having the interviewers identify themselves and place on record the date and time the interview commenced. The interviewer should establish the identity of the interviewee. The interviewee should state his/her employer, job title, and provide a brief employment history.
(3)
If a third party is present during the interview, the interviewer should establish on the record at the beginning of the interview that the presence of the third party was requested by the interviewee as his/her representative, and indicate the person's name, job title, and association with the interviewee.
(4)
The interview should begin by allowing the interviewee to tell what happened in his or her own way, starting from a time well before the event, but at a point well defined in the interviewee's mind (e.g., start of shift, lunch break). The interviewee should be allowed to tell what happened with little or no interruptions by the intemewer.
(5)
Note taking during the interview by llT personnel should be minimal and unobtrusive, and should cease if it is distracting the interviewee.
(6)
Followup questions should be kept simple; avoid ja gon or terminology that could be foreign te the interviewee.13e objective. Avoid questions answerable with a simple "yes" or "no". Questions such as " is it fair to say..." or "would you agree that..." are useful ways to communicate that the interviewer understands what the o
inte,viewee said. "Can you tell me anything more?" is a good yestion to ask frequently for subsequent explorations.
3-3
{
4 (7)
Documents presented or used during the interview should be referenced and entered into the transcript as an exhibit, assigned a number and provided to the stenographer to be included as a part of the transcript.
(8)
At the conclusion of the formal interview, the interviewer should ask the interviewee on the recerd if there is any other information the interviewee wishes to share with the llT that has not been specifically covered during the interview, and if the individual knows of any other individuals with knowledge of the event l
(9)
The lead spokesperson should obtain the interviewee's phone number and j
location where he/she can be reached for sub;equent followup qtiestions that may i
occur. In addition, the lead spokesperson should also provide the phone number and location where he/she can be reached should the interviewee recall additional information to share with the llT.
i (10)
A copy of " Guidelines for Review and Availability of Transcripts," Exhibit 31 is to be provided to all interviewees at the end of each interview.
)
1 e.
e 3-4
3.6 Exhibits Exhibit 3-1 Guidelines for Review and Availability of Transerinl3 The incident Investigation Team (IIT) has had interviews and meetings transcribed to assist the team in its investigation. Interviews should be transcribed overnight and, in
-general, be available for review the following day. Individuals wishing to review their transcripts should bring proper identification with them. Transcripts of interviews and meetings are available for review under the following guidelines:
_(1)
During the team's investigation, a copy of the transcripts of personal interviews will be made available for review only to individuals who were interviewed. In the case of joint interviews, each person who was interviewed may examine that i
transcript. Individuals may read only their own transcript, and may consult with personal counsel while reviewing the transcript. No copies of the transcript may be made.
n' (2)
Individuals may correct their answers on errata sheets (see attached form), which
(
will be attached to the transcript rather than on the transcript itself. ^1f anyone wishes to speak further with the llT, the team will be available for further interviews. These interviews will also be transcribed.
j (3)
After the conclusion' of the investigation, each individual interviewed, upon request, will receive a copy of the transcript of their own interview for their
- personal retention and use.
(4)
- After interviewees receive a copy of their transcripts, the transcripts will be transmitted to the NRC's Public Document Rooms where it will be available to
' the public.
(5)'
Transcripts of meetings between the IIT and the licensee will be available for-review by NRC personnel (including the Region) and licensee personnel. The licensee may make corrections on errata sheets, which will be included with the transcript, rather than on the transcript itself.
(6)
After the llT has concluded its investigation, copies of the meeting transcripts will-be provided to the licensee for its retention and use. The transcripts will also be made available to the public unless the licensee has made a request to protect proprietary and safeguards information in the transcripts in accordance with NRC regulations, k
3-5 L
Exhibit 3-1 (continued) 2-DIRECTIONS FOR MAKING COllitECflONS If you have any corrections that you wish to make on your transcripts, please do so on the following page in the following fashion:
Indicate the page to which the correction applies, the line number, the change to be made and the reason for making the change. Date and sign all correction pages that relate to your transcript.
If you have no corrections or clarifications, please state this on the following page and date and sign the correctica page.
O
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l 9l 3-6
B 1
T Exhibit 3-1 (continued)
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ADDENDUM TO INTERVIEW OI-l (Name/ Position) l fagg Line Correction _and Reason for CorrectinD I
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(O GUIDELINE 4: TREATMENT OF QUARANTINED EQUIPMENT 4.1 Purnose Guideline 4 provides guidance for equipment to be quarantined and related troubleshooting action plans (TAPS) during an Incident investigation Te m (llT) investigation.
Attention At all times, the licensee is resporuiblefor quarantined equipment and can take action inwiring this equipment that it deerns necessary to:
achieve or maintain safe plant conditioru e
preventfunher equiptrent degradation, or o
test or inspect as required by the plant's Technical Specificatioru t
To the maximum degree possible, these actions should be coordinated with the llT leader in advance or notification made as soon as practical.
(\\\\
4.2 Background
To learn how equipment failed or performed in an anomalous manner during an event, the llT must minimize the potential that the equipraent could be manipulated such that important information concerning its performance during the event could be lost. Thus, the Regional Administrator confirms that the liceasce has quarantined the equipment in its "as-found" condition, usaally through a Confirmatory Action Letter (CAL). Then the licensee develops a detailed troubleshooting action plan for systematic inspecting and troubleshooting the equipment in order to identify the probable causes for its failure or observed performance.
After the probable cause(s) of failure of a particular component or piece of equipment is determined, the equipment is released from quarantine.
l The CAL confirms the licensee's intention / plans, among other things, that any equipment that L
may have ma' functioned during the event be preserved, except as required for safety. in its present condition. Thus, the hcensee is to hold in abeyance all work (i.e.,
maintenance / testing, etc.) in progress or that is planned for the equipment. The IIT leader is ausorized to define and revise the quarantined equipment list (QEL), and to review and approve TAPS.
l(Gm) 4-1
4.3 QuarantinesLEquipmenLLhilREL)
The QEL should be limited to that equipment that was significantly involved in the event.
For example, only that equipment that failed or malfunctioned during the event and had an impact on the sequence of events should be included. Equipment can be added or deleted from the QEL as the investigation progresses and remains on the QEL until the llT leader determines that the probable causes of failure have been identified or that its performance was not a signi6 cant contributor to in: event. Quar;mtining equipment carutsult in a signiftCant disruption to the licensis activities., so thelcam should minlalizelhelmpact to the maximulu degree oossible.
The llT and licensee representatives should reach a common understanding sbaut the scope of the QEL., why each piece of equipment on the initial list is there, and what the boundaries of the quarantine are. Boundaries should include relevant components and/or systems that may have caused or contributed to the failure or obscrved performance of the equipment.
If there is a conQict about an item on the QEL that the llT believes is vital to its mvestigation, the llT leader and the licensee should agree on a process to minimize the amount of key information that could be lost. If the cor.Gict cannot be resolved to the satisfaction of the IIT leader, he or she should inform the Director, AEOD, of the problem and obtain guidance for its resolution. The llT leader should review procedures developed by the licensee to meet the limiting condition for operation as well as minimizing the amount of key information that could be lost. The following guidelines govern QEL handling:
(1)
The QEL should be compiled and maintained by the licensee, and reviewed and approved by the IIT.
(2)
The QEL is subject to multiple revisions. The current QEL should contain its revision number, date, and the changes made to it from the previous version.
(3)
The QEL and its revisions should receive prompt and wide distribution including the llT, NRC Offices, the Region, and licensee organizations, e.g., as part of the Preliminary Notification (PN) status report.
(4)
Equipment on the QEL should be clearly identified and secured in the plant (roped-off, tagged out, labeled, etc.) to the extent practicable. A licensee-designated individual for the particular equipment should be idcatified such that he or she can be contacted when access to the area / equipment is necessary.
4.4 Troubleshootine Action Plans Establishing TAPS for quarantined equipment are necessary to provide a process by which the probable causes of the conditions ob:;erved and equipment malfunctions can be ascertained. It is important that the troubleshooting activity on the equipment does not inadvertently result in 4-2
(
loss of information accessary to conGrm postulated causes of equipment malfunctions. TAPS ensure that the troubleshooting is systematic, controlled and well documented, and that adequate records on the as-found condition of malfunctioned equipment are maintained.
A proven method of minimizing the time spent in reviewing TAPS, yet ensuring their completeness, is for the llT and licensee to agree on generic guidance that will be part of each TAP and included in the troubleshooting activities. From the generic TAP, specific TAPS (one for each piece of equipment quarantined) should be developed by the licensee.
The following guidelines apply to the development and use of TAPS:
P (1)
For each item on the QEL, a TAP should be developed by the licensee for investigative or troubleshooting work and reviewed and approved by the llT leader prior to implementation. In order to minimize delays, if possible, the llT should complete its review of all TAPS prior to leaving the site.
(2)
Additional guidance for investigation or troubleshooting equipment is contained in Exhibit 4-1. An example TAP is provided in Exhibit 4-2. These guidelines and the exhibits can serve to help guide the licensee's activities and should be provided for his/her information and consideration.
(3)
The licensee should advise the llT/NRC regional representative as soon as practical of work plans and schedules so that arrangements can be made with the regional office to 3
have NRC staff available to observe troubleshooting activities.
(4)
Repairs and corrective actions on the quarantined equipment should not proceed until the IIT has approved the removal of the piece of equipment from the QEL.
(5)
The TAP must clearly document the scope, affected equipment and the objectives of the troubleshooting activity, and should be a self-contained document that provides a de6nitive bases for the troubleshooting work. In general, the llT may review maintenance work packages for information, but will not formally approve them.
(6)
The TAP should document all as-found conditions, such as any missing, loose or-L damaged components, and note component configurations or any abnormal environ-mental conditions. Whenever possible, photographs should be used to document as-found conditions._ When necessary, samples of Gulds or their residue should be i?
- retained for further analysis.
l (7)
A cognizant licensee engineer knowledgeable in the design and performance requirements for the equipment under consideration should be identined to be the point of contact for each TAP.
-(8)
The TAP should include or require a review of all known information and data defining conditions existing prior to, during, and after the event. This information 4-3 l
LE
should include maintenance, surveihance, and test histories and any changes in design or in the method of operating the equipment and/or system. Significant findings from this review should be used in formulating hypotheses for the probable causes of equipment and/or system anomalies.
(9)
The TAP should include, if possible, a requirement to test the equipment during conditions under which the system, train or component failed to operate properly.
Such tests are extremely desirable when the causes of the failure are not obvious.
When actual conditions cannot be reproduced, simulated conditions may suffice if their limitations are specified on testing results.
(10)
The TAP should indicate the probable causes of the equipment malfunction and include precautions against the destruction of substantiating material evidence.
(11)
The TAP should address the degree of participation by vendor representatives.
Vendor representatives should at least be contacted to discuss the performance of the equipment. Their participation should be encouraged if appropriate licensee expertise is not available. Vendor representatives are also expected to follow the action plan.
(12)
The TAP should list the sequence of troubleshooting activities and procedures. If the sequence can be determined prior to the activity being performed, then that sequence should be specified, with a check-off for each step. If a specific sequence cannot be determined prior to the activity, a general sequence should be identified, with specific steps documented as they are performed.
(13)
The sequence of troubleshooting activities should include hold points to enable observation and phctographic documentation of conditions found. NRC regional staff will normally provide oversight during the troubleshooting activities.
(14)
Repairs or corrective maintenance to equipment should not be part of the TAP. These aspects will be handled separately by the licensee and the NRC following the troubleshooting process.
(15)
The TAP should specify that when conditions other than what might have been expected based on the developed hypothesis (ses) are noted during troubleshooting, work thould cease and appropriate licensee and NRC personnel consulted prior to continuing with the action plan.
(16)
The TAP should state that all replaced components / equipment should be retained for subsequent review and examination, and that complete traceability should be maintained. Damaged equipment should not be discarded or shipped offsite without prior IIT leader approval. The IIT may require that the failed components be examined by an independent laboratory.
4-4
(17)
The completed TAP and the schedule for the implementation of troubleshmting activities should be reviewed by the llT before completing the initial onsite phase of the investigation. A coordinated approach should be established so that, to the degree possible, llT activities do not unnecessarily dday implementation of licensee recovery actions.
(18)
The licensee should no..fy the llT when the probable cause of each equipment malfunction / failure iias been identified. Agreement should be reached with the licensee on the extent, nature, and schedule of the troubleshooting documentation.
(19)
Equipment is released from the Qlil. after the ilT leader determines that the probable causes of failure have been identitied or that its performance was not a significant contributor to the event.
4-5 l
1
4.5 Exhibits Exhibit 41 Osrgic_Quidelires for Tropbleshooting the Pmbable Causes of Equipment Anomalies For each item on the Quarantined Equipment List, a troubleshooting action plan (TAP) should be developed by the licensee for investigative or troubleshooting work which provides the basis for the work instructions. Licensee personnel (lead and/or support) developing the TAP should be identified on the TAP and should have knowledge of the design criteria of the specific area being considered. Vendor engineering support will be utilized as necessary to accomplish this requirement. When used, vendor assistance should be documented.
All troubleshooting activities should be preceded by event evaluation and analysis to determine the hypothetical and probable causes of failure or abnormal operation. Conduct the analysis and evaluation as follows:
(1)
Collect and analyze information and operational data for conditions prior to, during, and after the event.
(2)
Review maintenance, surveillance and testing histories.
(3)
Develop a summary of data including 1 and 2 above, that supports any proposed probable cause of failure or abnormal operation.
(4)
Conduct a change analysis (i.e., what has changed since the last known successful operation of the system or equipment).
(5)
Based on items 1-4, develop primary and alternate hypothesis (ses) for the probable cause of the problem.
(6)
Develop plans for testing the probable causes and hypothesis (i.e., checks, verifications, inspections, troubleshooting, etc.). In developing inspection and troubleshooting plans, take care that the less likely causes/ hypothesis (ses) remain
- testable, (7)
When planning troubleshooting, try to simulate as closely as practical the actual conditions under which the system or component failed to operate properly during the event.
]
Ol 46
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i 1-4.
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Exhibit 4-1 (continued):
d-It is very important that the investigation not result in the loss of information caused by disturbances to components or systems, investigations need to be conducted in a logical, well thought-out, and documented manner.
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Exhibit 4-2 Eliultde Itnuhksheet.ingAci!cti P1an fTAP)
TITLE: TAP FOILMA.lN FEliD PUh1P CONTROL SYSTFht Report by:
Chris Tolpram Plan No.1 Tony Grimes Date Prepared: June 18,1985 This report has been prepared in accordance with the " Guidelines to Follow When Troubleshooting or Performing Investigative Actions into the Root Causes Surroundmg the June 9,1985 Reactor Trip," Rev. 2.
INIXODUCTORY STATEN1ENT This TAP is the first step in addressing Con 0rrnatoly Action Letter Item 4a, establishing the cause of main feed pump turbine (h1FPT) i-l trip. Item 4b will be addressed at a later date.
SUhth1ARY OF DATA _
The following is a discussion of the events which took place prior to and shortly after the No.
1 MFPT trip on June 9,1985.
On June 9,1985 at approximately 1:22:49 computer alarm Q 626 indicated "MFPT 1 hiain Oil Pump 1 ON," This indicates the standby main oil pump started approximately 12 minutes before No. I htFPT tripped. The Data Trend Table for No, I h1FPT speed indicates that turbine speed increased 29 RPhi and then decreased 23 RPhi at approximately the same time the standby main oil pump started. This indicates that control valve movement dropped the hydraulic header pressure to < 170 psig, therefore starting the standby main oil pump.
Since the h1DT 20 control system was installed, valve movement, as described above, has started the standby main oil pump due to the quick response of the unit. Another indication that the control valves moved is ti,e feedwater Cow recorders. Approximately 12 minutes before hfFPT l-1 tripped, the cherts indicate a change in feedwater flow to both Steam Generators.
The data available concerning No.1 MFPT trip indicates that the trip was caused by an actual overspeed condition Recording charts, hooked up after the June 2 problems, show that Limit Switch LS16 was the first indication of a trip LS16 provides tripped indication of the trip dump valve Under corraal conditions the trip dump valve will trip due to solenoid valve SV-4-8
h
' Ihhibit 4-2 nontmucd) 12 energizing..the manual trip lever being actuated, or by the emergency governor plunger
- due to an overspeed condition. The chart recorders indicate that the hydraulic trip solenoid valve SV-12 did not energize when MFPT l-1 tripped. Therefore, the trip protection devices associated with SV 12 have been eliminated as possible causes of the turbine trip.
Using the computer readout of turbine speed as an indication for speed change with respect to time, it can be seen that MFPT l-1 increased speed by approximately 1591 RPM between 1:34:24 and 1:34:53. This change in speed would be more than sufficient to reach the setpoint for the emergency overspeed plunger to actuate therefore causing the trip dump valve to trip.
The emergency overspeed trip device should actuate between 5866 RPM and 5984 RPM (reference: MPPT Manual GEK 83602). - Testing performed after the MDT 20 was installed during the 1984 refueling outage shows that MFPT l-1 tripped on overspeed at 5920 RPM, 5888 RPM, and 5892 RPM. This testing was performed per PT5136.03, MFPT Overspeed Periodic Test, which requires three consecutive acceptabic overspeed trips.
Another indication that MFPT l-1 speed increased is the feedwater Oow charts. At approi ty 0135 on June 9, a step increase of approximately 2.5 mpph feedwater flow 1
. occurreo toi total feedwater flow to Steam Generator 1 1 and 1-2. At this time, MFPT l-1 was in " AUTO" and MFPT l-2 was in " HAND". This rapid change in feedwater flow
~ indicates that MFPT l-1 increased speed, therefore increasing total feedwater flow to the Steam Generators. The turbine speed increased until MFPT l-1 tripped due to an overspeed condition which initiated a plant runback due to a loss of MFPT l-1 above 55% power.
Following the trip MWO l-851935-00 was initiated on June 9th to attempt to troubleshoot the cause of the MFPT trip. Under this work order voltage readings were taken on MFPT l-
-.1 and compared to readings taken on MFPT l-2. No significant differences were noted. All work on this MWO was halted on June 9th.
Maintenance And Test History
. ihe MDT.20 control system for the MFPTs was. installed during the 1984 refueling outage.
After installation of the MDT 20 control system, Test procedure TP520,83, '" Main Feedwater Pump Turbine and' Auxiliary Support Systems," was performed to test the equipment.
Testing requested by MPR Associates, Inc. was performed by TED personnel on installed equipment in November and December of 1984 which included:
, O V
(1)
A test to establish the dynamic input / output characteristics of the MDT 20.
4-9
O lhhibit 4-2 (continwil i
(2)
A test to establish the steady state input / output characteristics of the h1DT 20 valve positioner.
(3)
A dynamic response test of the MDT 20 valve positioner.
(4)
A dynamic response test of the h1DT 20 governor during feedwater flush, Analysis of these tests by MPR concluded that the MDT-20 governor will provide satisfactory feed pump differential control with internal settings as recommended by GE and the Integrated Control System (ICS) settings established prior to the outage with the hillC governor.
Discussion of events concerning April 24th trip:
During operation at 98% full power a Oux/ delta Dux/ flow RPS trip occurred. Ap-proximately eight seconds after the Reactor trip, MFPT l-1 tripped. The cause of the MFPT trip 5,as never positively identified.
Testing was performed to determine if the thrust bearing wear detector trip circuitry could pick up if the standby oil pump is started Test gauges were installed per MWO l-85-1442-00 in place of the pressure switches and the standby oil pump was cycled to see if pressure would increase to the trip setpoint. During ~his testing, pressure did not increase to the trip setpoint. The turbine was also ran throup' ifferent speed changes to determine if oil pressure could have dropped to trip the '
me. The turbine speed was increased at three different initial speed settings consis 3 of the following:
(1) 3700 RPM to 3900 RPM (2) 3500 RPM to 3900 RPM (3) 3300 RPM to 3900 RPM This testing indicated that the oil pressure did not decay to the trip setpoints.
Periodic test PT 5136.06, "MFPT Emergency Overspeed Governor Tests," was performed to test the overspeed governor. This test was completed successfully.
In addition to the testing which was performed, the following irmruments were recalibrated:
(1)
The active and inactive thrust bearing wear detector pressure switches.
(2)
The turbine bearing low oil pressure trip switches.
(3)
The feedpump baaring low oil pressure switches.
(4)
The main feedpump high discharge pressure trip switches.
(5)
The MFPT vacuum trip switches.
4-10
- ~
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a 1
Exhibit 4'-2 / continued)
(6).
The RFR target speed voltage was adjusted from 4.0090 VDC to 3.6045 VDC.
Discussion of events from June 2nd trip:
During main turbine control valve testing, a high turbine vibration signal tripped the main turbine. The ARTS trippcd the reactor. Within four secouds after the turbine / reactor trip, both main feed pump turbines tripped.
- Pri. Theory The theory behind both the MFPTs tripping concerns the following four parameters:
(1)
Rapid Feedwater Reduction (RFR) target speed being set too high due
- to not adding in a bias to the RFR setpoint.
From January,- 1985 until April 24,1985, the RFR target speed was
. thought to be set at 4800 RPM, when in fact it was actually 5150 RPM.
+
Following the April' 24 trip, the RFR target speed was thought to be reset to 4600 RPM, when in fact it was actually 5000 RPM. Reference-MWO l-85-1489-00.
Following the June 2nd trip, it was found that a voltage bias needed to be added to the RFR setpoint. RFR target speed-was reset to 4600 RPM. Reference MWO l-85-1908-00.
(2)
Main steam header pressure increasing to approximately 1070 psig after
- the reactor tripped causing the. MFPT speed to increase.
-- (3) -
Booster feed pump suction pressure increasing due to increasing deareator level plus deareator pressure. This would cause main feed pump discharge pressure to increase.
l -
.(4)
Feedwater valves partially closing down causing MFP discharge-pressure to increase.
Based on the above four parameters. there is a possibility that the MFPTs
- tripped on high discharge pressure of 1500 psig, which is one of the trips that could have tripped both pumps almost simultaneously.
k.
.. Alt. Theory Quick response time associated with the MDT 20 hydraulic control system -
could cause hydraulic oil pressure swings which could have i
4-11 L
Exhibit 41Ranum):d) activated trip circuitry. This theory is not conclusive based on the following:
Testing indicated that the MFPTs would r.ot trip after the hydraulic control system was subjected to rapid swings by cycling the control valves.
Based on the above theory, the MFPT l-1 control valves were cycled repeatedly through full stroke cycles as fast as possible with the Gli representative. This we.s performed to try to decrease the oil pressure to activate trip circuitry associated with the hydraulics. No MFPT l-1 trips were activated. The testing indicates that the MDT 20 hydraulic control system responds from the valves crack point to full open in approximately 0.6 seconds.
Continued testing by GE identified that the #1 MFPT could be tripped when stopping the #2 Main Oil Pump (MOP). If the #2 MOP was left in-service for a period of time and then turned off, the #1 MFPT would not trip. It v as recommended by GE not to turn off the #2 MOP on #1 MFPT until after it had run for awhile. This was only a short-term solution to the problem. The long-term solution will be to inspect both MOP discharge check valves along with PRV3 during a major outage.
While increasing power and performing PT5136.01, MFFT Stop Valve Periodic Test, on #1 MFPT, #2 MOP came on during stroke valva testing. The operators left #2 MOP on for approximately 20 minutes as instructed and then shutdown the #2 MOP after which the #1 MFPT tripped. At 0155 the plant was at approximately 56% power and experienced a runback to 55% power.
Repeated testing after the June 5,1985,0155 MFPT l-1 trip:
0630 After stopping the #2 MOP MFPT!-l would trip.
~
0800 After stopping #2 MOP the MFPT tripped two out of six times.
1400 After stopping #2 MOP the MFPT would not trip. This was performed numerous times with the MFPT on turning gear and at speedt of approximately 4000 RPM's.
1900 Broke vacuum to install additional instrumentation to monitor the active thrust bearing pressure switches.
Additional testing was performed and the MFIYF would not trip when either #1 or #2 MOP was stopped.
4-12 1
T O
Exhibit 4-2'(contjDutd)
GE factory personnel and representative felt that the #2 MOP discharge check valve was sticking open and remained open momentarily after stopping #2 MOP. Under this-condition, #1 MOP-would pump oil back into the #2 MOP impeller and the 55 psig.
header pressure would decrease. --it is possible that the check valve remained open long enough to have the pressure control valve that reduces pressure from 250 to 55 psig (PRV3) to open to maintain header pressure at 55 psig. After the #2 MOP discharge check valve seated, preventing back flow, with PRV3 open, the 55 psig header could experience a pressure surge picking up the thrust bearing wear detector -
trip circuitry.= Based on repeated testing, the cause for the check valve to remain open evidently cleared itself.
Strip chart recorders were connected to monitor particular electrical signals and oil system pressures after the June 2 trip to determine the cause of MFPT l-1 trip which initiated the-reactor trip. The recorders were hooked up to monitor the following information for MFPT l-1.
CTRM Cabinet Room:
(1) - Lube Oil Pressure to feed pumps (PS25)
(2)
Bearing Header Pressure (PS19) s
'(3)- Thrust Bearing _ Wear (PS 2 & 12)
(4) ~ Main Feed Pump Discharge pressure (Q628)
'(5 Speed Reference Signal (TPl11)
Locally at MFI'I' 1-1:
~(1) ' Limit switch LS16 (2)
Solenoid valve SV12
-(3) l Hydraulic header pressure
-(4)
Control oil pressure L
(5)
Thrust bearing weai detective (Active)
FAILURE HYPOTHESES
SUMMARY
l L
On the April-24th and June 2nd trips, the reactor tripped and the MFPT(s) tripped shortly K
afterwards. On the June 9th trip, the MFPT initiated tl.e transient which caused the reactor i-
-) trip; On the April 24th and 'the June 2nd trips there was no apparent MFPT overspeed L
condition; On the June 9th, trip we very clearly saw an indication of a MPPT overspeed icondition. As a result l we feel that the June 9th trip is unrelated to the previous trips. ' We -
-will continue to' monitor electrical and oil pressure signals.
4-13
Exhibit 4-2 (continued)
On June 9, the chart recorder monitoring the speed reference signal shows that demand speed for MFPT 1-1 was steady until actual turbine speed increased and the main feedwater control valves began to close due to the increased feedwater Dow. The ICS speed control for the h1FPTs is derived from the pressure drop across the feedwater control valves and from the feedwater demand signal. Due to a developed feedwater Dow error signal, the main feedwater control valves closed down and the pressore drop across the valves increased. The ICS turbine speed control circuitry responded properly by reducing the speed reference signal (demanded turbine speed). This indicates the ICS input signal and the MDT 20 electronic circuitry which produces the speed reference signal did not cause the overspeed condition. This also rules out an inadvertent RFR initiation.
An electrical connection problem / malfunction may have developed in the MDT 20 circuitry (excluding the circuitry producing the speed reference signal).
Another possible explanation for the overspeed trip is a hydraulic / mechanical control system malfunction which drove the steam control valves open, therefore, causing an overspeed condition.
Another possible cause for the overspeed condition could have beca a mechanical coupling failure between the pump and t irbine. Since feedwater now increased as turbine speed increased, this possibility was ruled out.
An industry poll by MPR revealed that an overspeed failure occurred in an Indiana power station due to a faulty MDT-20 speed circuit. A for;ner G.E. Service Representative was contacted, and he recalled troubleshooting a high speed failure due to a faulty frequency to voltage integrated circuity.
There is indication from the feedwater Dow recorders that the problem may be intermittent, which may make it extremely difficult to locate the problem. This fact is also recognized by G.E.
CHANGE ANALYSJS Un';l the 1984 refueling outage, the MFPTs were equipped with mechanical / hydraulic speed governors (General Electric Model MHC). These MFPTs were replaced with more modern electrical / hydraulic speed governors (General Electric Model MDT-20) installed per FCR 81-075.
(1)
After the April 24,1985 trip, the following work was performed:
O 4-14
O Exhibit 4-2 (contmuedl Installed Test gauges on April 24,1985, in place of the active and inactive thrust e
bearing wear trip pressure switches PS 2715 and PS 2717. Disconnected the test gauges and reconnected PS 2715 and PS 2717 on 4 25 85 per MWO 1 1442-00.
Recalibrated PS 2715, Active thrust bearing wear trip pressure switch, per MWO l-851451-00, Recalibrated PS 2717, inactive thrust bearing wear trip pressure switch, per o
MWO l-85-1451-01.
Recalibrated PSL 1161, MFPT l 1 turbine bearing low oil pressure tiip switch, per M W O 1-85-1451-02, Recalibrated PSL 1192, DFP l-1 bearing low oil pressure trip switch, per MWO e
1-85-1451-04, o
Recalibrated PSli 506, MFPT 1-1 discharge high pressure trip switch, per MWO l-85-1451-04.
Recalibrated PS 2535A and PS 2535B, MFPT l-1 low vacuum pressure trip switches, per MWO l-84-1451-05, o
Recalibrated the Rapid Feedwater Reduction (RFR) Target Speed Setpoint from 4.0090 VDC to 3.6045 VDC which was thought to correspond to 4600 RPM.
(2)
After the June 2,1985 trip, the following work was performed:
Additional MFPT System test points were monitored and recorded by field mounted strip chart recorders installed per MWO l-85-1887-00 and 01.
Again recalibrated the RFR Target Speed Setpoint from 3.6045 VDC to -2.000 VDC which corresponds to 4600 RPM per MWO l-85-1908-00.
Operational change: #1 Main Oil Pump was changed from primary to backup service and #2 Main Oil Pump was changed from backup to primary service.
Operational change: #2 MFFT was placed in ICS manual operation from automatic operation. #1 MFN was left in automatic oper:. tion.
O 4-15
.....)
Exhibit 4-2 feontinued)
HYPOTHESES INVESTIGATION Based on the information gathered, it appears that several conditions could have caused h1FPT l-1 to overspeed:
(1)
Loose connections associated with the electrical circuitry Lr the htDT 20 system.
(2)
A circuit board component malfunction.
(3)
Hydraulic /htechanical control problem.
ACTION Pl.AN 1 ALL STEPS OF THIS TAP ARE TO BE PERFORh1ED IN ACCORDANCE WITH THE LATEST REVISION OF " GUIDELINES TO FOLLOW WHEN TROUGLESHOOTING OR PERFORh!!NG INVESTIGATIVE ACTIONS INTO THE ROOT CAUSES SURROUNDING THE JUNE 9,1985, REACTOR TRIP " ACTION PLAN STEPS WILL BE PERFORh1ED IN THE SEQUENCE LISTED.
(1)
LOOSE CONNECTIONS:
Visual inspections and troubleshooting will be performed locally at tne pump and at the control cabinet. A log will be maintained to document the troubleshooting performed and the findings. A DVOh! or an oscilloscope will be used to monitor connections while performing these checks.
~
(2)
CIRCUIT BOARD COh1PONENT h1ALFlINCTION:
Under the directions of a GE representative, using a checklist per the work instructions, an electrical check of the circuits will be performed and no adjustments will be made.
A log will be maintained to cocument the tests performed and the findings. Particular g
boards of interest are:
Redundant Speed Pickup Circuitry Speed Summation & Valve Lift Reference Circuitry Operator & Pilot Valve Position Feedback Circuitry Servo Amplitier Circuitry Function signal generators may be used for input signal 4-16 l
O lhhibit 4-2 teoritinuce (3)
IlYDRAULIC/MEChlANICAL con iI.L SYSTliM:
c Testing of the hylraulic and inechanical control system wil! be performed i
ler Gfi recommendations. Tests such as cycling the valves through full
)
stroke may be performed along with other Gli recommendesi tests. While moving the valves, testing of appropriate electrical signals niay also be per formed.
Sample oil and inspect filters for contamination.
e (4)
If the root cause is i,at determined from steps 1,2, or 3 then an aux / main steam run of MFPT 1 1 will be performed to obtain data to compare to previous information gatheud earlier by MPR. Gli may also perform additional checks, (5)
If the root cause is not determitied from steps i,2,3, or 4, then the following will be performed:
The circuit boards will be sent to GB for stress tests in an attempt to locate a failure.
A field wiring check will be performed, such as a mcgger test.
4-17
GUIDELIMii 5: PREPARATION OF Tilli INCIDlWF INVESTIGATION TliAM REPORT AND FOLI.OWUP STAFF ACTIONS 5..
h!ID01c Guideline 5 provides guidance for the preparation, release and distribution of the Incident investigation Team (llT) tcport and fo"owup staff actions resulting from the investigation.
5.2 Backcround The purpose of the incident investigation report is to document in clear and concise languay the results of the llT investigation. The Office for Analys:s an Evaluation of Operational Data (AEOD) will coordinate with the Director of the Of6cc of Administration to provide staff to assist team members in writing, editing, word processing and printing of the report through the Divirion of Freedom of Information and Publication Services. Followup staff actions directed by the Executive Director for Operations (EDO) will be based on the report findings and conclusions.
5.3 Writing and Publishing Guideliac5 These guidelines list the sections that typleally appear in an llT report and describe the genera! approach for how each should be written or by whom it will be compiled. An example of an llT report table of contents is presented in lixhibit 51. A checklist for report preparation is provided in Exbibit 5 2. Th% section also provides guidelines for the following report preparation requirements:
- submitting graphics material e transmitting advance copies of the report e scheduling preparation of the report 5.4 Renort writin_c Guidelines (1)
The coret, litic page, and sping should be sent to the.^ utomated Graphics Section for preparation by the technical writer / editor assigned to the team.
(2)
The EUREG numbei will be obtained by the technical writer / editor.
(3)
Yhe ab1Iacj should be 200 words or less, and describe the "what, where, m d when" l
about the incident and the *how," as space permits. It should state the num's task, O
that it was sent by the EDO, and that the report contains findings and cc..clusions.
V The abstract should acj discuss findings and conclusions.
5-1
9 (4)
'lhe [dbltelcDn!LDb should be compiled by the technical w riter/ editor.
(5)
Tne lilleff!"uicultidlahk3 should be compiled by the technical writer / editor.
(6)
The acknnEkdgemenLiedien should list the names of team members and acknewledge any significant auistance the team received in preparing the report.
(h The agenyfuLand2blutriadentdecutut should be compded by the technical writer / editor. in the test, terms for which acronyms are used should be spelled out the first time they are used, followed by the acronym in parentheses. Thereafter, the acronym can be used. This practice should be followed for cach_nudeugetien of the reivrt.
(F)
The report tsegudytiunumity._section should begin with a brief background statement cor;taining the facility's name, utihty, location, reactor type (or type of facility process and materials involved), and date licensed for operation. The esecutive summary should contain a brief description of the incident. In a separate paragraph, the puriuse and scope of the llT should be described, followed by a description of what is contained, section by section, in the remainder of the report. Nest should be a sununary of the team's conclusions with a short discussion on each conclusion followed by a suunnary description of the team's Ondings and conclusions.
(9)
The stIIadYLittlien of the report tells the story of the incident in chronological order from start to finish. Time markers should be used throughout the description to keep readers abreast of the sequence. The use of a.m./p.m. chick notations should be used.
The use of transitional terms that specify time ("in the meantime," "at this point,"
"before," "after," "then") should also be used. The narrative should be written in the past tense and descriptions of activities of the people involved in the event should be in the third person, unless someone is quoted directly. The person speaking should be identi0ed by job title. The narrative should not be interrupted with lengthy explanations. A sentence or two of explanation cucctial for the reader to undentand the significance of what is being described is appropriate.
(10)
The sy11tmJ cStripieBhlr$Penht2htLtra!Oalienattdea should begin by providing a l
br.f overview statement of what function a system or subsptem performs and of how it is integrated with other pertinent systems befmr a detailed description of the system or subsystem is given. This should be followed by a narrative of the sequence of events with a description and evaluation of performance. Equipment and systems should be referred to in the same terms consistently. The terns and abbreviations that are used in the test should be identical to those on figures.
(11)
The humar pciformance.Senurallentattnen should be writtea from the point of a
view of the people who operate or repair the instrumentation and equipment being 5-2
l i
described. iluman performance errors and omissions should be described objectively, j
not judgmentally, judgments are appropriate for the conclusions section, l
l (12)
The piefuth0IutcliOD should document all precursor events fully, carefully distin-guishing between facts and opinions. Opinions should be identified as such. In peneral, this section should pertain to all similar events applicable to the event at the facility, e.g., if it could have happened at that plant, it is a precmsor.
A section of t t; nit.imnt items of_inicInt found during the investigation but that wcw i
(13) not directly sluMI to the event should be included in the report as needed (e.g., a sig-ni6 cant desjn &.clency that did not play a role in the event was found during the review of a drawing of a system).
t (14)
The Endings and_cenglusions section should distinguish clearly between findings and conclusions. A D.0 ding is what the team learned or "found" based on the faclual information collected during the investigation. For example: a piece of equipment failed; its failure caused the loss of a system; operators did not respond quickly to the system failure; procedure manuals did not address this specific sequence of events. A conclusion states a judgment and specides the significance or implications of a finding.
For example: the equipment failed because of poor maintenance; operators were not t
properly trained to respond to the sequence of events that occurred; the procedures need to be revised to address this sequence of events, The findings and conclusions in this section must be correlated carefully with those discussed elsewhere in the report.
The Ondings and conclusions section should not introduce new information; i.e.,
[
nothing should appear as a finding or conclusion for which the basis is not provided in the report; conversely significant issues in the report should be reflected as findings and conclusions.
In general, for early drafts, it is easier to put the Ondings and conclusions in the text where they logically would occur and to label them with a heading, " conclusions."
This way they can be easily identified when the Ondings and conclusions for the entire report must be compared for accuracy and consistency before being compiled in a separate sectmn, in later drafts, they can be collected into a separate section and the labels in the text removed. This system makes it easier to ensure that there is adequate support for each conclusion.
(15)
The I.c{clencuccliRD should contain only accurate and retrievable references which are essential to establishing the basis or credibility of tiie llT report. The reference format style in the NRC Editorial Style Guide (NUR11G-1379) is preferred. The technical writer / editor will assist with the reference format.
(16)
The @Stadittucc. lion should ir.clude the llT charter as Appendix A. Appendix B includes a description of the fact.6nding effort and the methodology used by the team l
in conducting the investigation, This section should include a table of interviews and 5-3
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i meetings, identifying those interviewed by job title rather than name. Additional appendices should contain material that clarifies or supplements a finding or explanation crucial to the incident but that is so detailed or voluminous that it would impede readers if it appeared in the body of the report.
5.5 GIa1911c D1!idelines The following guidelines provide instructions for submitting work to the Graphics Section.
(1)
All work should be submitted by the originator so ', hat he/she can answer technical questions, if necessary. Figures should be coordinated for editorial and tracking purie,es with the technical writer / editor before being submitted to Graphics.
(2)
Original artwork should be submitted when possible.
(3)
For original artwork, instructions should be put in writing. The team member should retain a copy of the artwork and instructions to answer any followup questions the Graphics staff may have.
(4)
Team members should put their names and telephone numbers on the luck of each figure submitted.
9 (5)
Artwork for previously published work (from another report or manual), should be submitted in the original or in the best copy available. Changes should be marked on a copy of the original in red.
(6)
If the original appears in a copyrighted source, permission to reproduce it should be obtained before the llT report is issued. The technical writer / editor will provide the appropriate copyright release form.
(7)
If appropriate, the name of the source from which the original was obtained should be acknowledged.
(8)
For oversized artwork, the original, not a reduced version, should be submitted.
(9)
Changes to existing artwork should not be marked on the tissue overlays. Mark them only on a photocopy of the original.
(10)
The terminology and abbreviations in the text and in the figures should be consistent.
(1l)
Equipment diagram symbols should be defined.
O 54
r t
(12)
Zeros should contain a diagonal line through them to distinguish them from the letter
- 0. Likewise, the letter Z should contain a horitontal line through it to distinguish it from the number 2.
(13)
For photographs requiring callouts (labels), the callouts and arrows should appear on the photocopied version. (No writing should appear on the face of the actual photograph.) The original photo and a marked copy should be submitted together. As with other figures, the submitter's name and telephone number should appear on the back of work submitted. Labels should be used to write on the back of the original i
photograph.
(14)
If the photograph is to be cropped (i.e., only a gurtion of the original is shown), the crop marks should be marked on a photocopy of the photograph.
(15)
Paper clips should not be used on a photograph without padding.
5.6 Publication Forms l
-_The following forms are required to be filled out in ord to publish the llT report as a NUREO document:
(1)
Form 426, Publications Release for UnclassiGed NRC Staff Reports. This form is filled out by the technical writer / editor and signed by the llT leader.
(2)-
Form 335, Bibliographie Data Sheet. This form is filled out by the technical writer / editor.
5.7-Distribution of the Advance Cppy
_ lt will be necessary to circulate _ an Advance Copy of the team's investigadon report if a Commission briefing is scheduled because the final published NUREG will not be available before the briefing. Each copy of the report will clearly indicate on the outside cover that it is an " Advance Copy," and will be stamped for "Of6cial Use Only" (OUO). Information contained in the report is not to be released publically until the day of the Commission briefing, when a copy will be placed in the NRC's Public Document Room (PDR). The i
techrical writer / editor will consult with the IIT leader to determine the proper report distribu-a tion for the Advanced Copy. - As a minimum, the NRC Commissioners, EDO, Office Directors and Deputy Directors, Regional Administrators, the IIT should be on distribution for an Advance Copy. AEOD will make arrangements to have couriers deliver the Advance 7
Copies to the Commissioners and to the EDO as soon as they are available.
On Gje day of the Comruission brienng, an additional 75 copies of the team's report will be requittd for the Commission briefing and delivered by courier to the Of6ce of the Secretary on :he day of the brienng. These copies will act be marked 000 or " Advance Copy " The 55 i
I -
-_ _ m _ _. _ n, -
,-.,_--,_,,,_,m_,.,_,_-
EDO may forward a copy or this sersion of the llT report to the affected licensee before the Conunission brieGng, and aimitlliulr0tt@ forward copies of the report to the Public Document Room and the appropriate neal PDR. Following the Commission briefing, the EDO will formally transmit a copy of the team's Gnal investigation report to the licensee and the staf f for review and connuent. The purpose for this is to allow the licensee and the staff an op;wtunity to provide cornnents on the team's report prior to the EDO de0ning and assigning followg, actims to NRC of 6ces. Any subsequent information conectning the Onal report, such as hcensee and NRC staf f comments, will also be placed in the appropriate PDIL 5,8 DiMIlbutiefLolt!!Ll%liihedEUREO The technical writer / editor will arrange for proper report distribution after consulting with the llT leader. As a minimum, distribution should be made to NRC liranch Chiefs and abose (technical ofnees only), including Regional Ol6ces, all resident inspectors, and enough copies for all appropriate licensees. In general, the Regional Administrator of the affected Region LSould receive 15 copies and AEOD should receive 75 copics of the reiwt. The final copies for llT members will come from AEOD's allotment. The technical writer / editor should call the Of0cc of Governmental and Public Affairs and the Advisory Committee on Reactor Safeguards ( ACRS) to learn of their requirements.
5.9 StafLActiGILDCICIminatienjwiAnigg1tt1l Af ter completion of a draft version of the report, the Director AEOD, in coordination with IIT leader should review the report findings and conclusions to determine which issues might be recommended to the lido for consideration as followup staff actions. 'Ihe suggested followup staff actions are not part of the llT report. Staff actions will either be generic or plant specine. Generic actions might involve staff review of regulatory requirements, the need for operational experience feedback communications, or a review of NRC practices.
Plant specific actions would normally involve regional or headquarters inspections or reviews of licensee corrective actions following the event. To the extent possible, suppested followup actions should be compiled so as to pull together related findings under a broad-scope action item. Individual actions suggested should be documented separately. When compiled, the suggested staff actions will be transmitted as an enclosure to a memorandum issued by the Director, AEOD, to the EDO for consideration and review. The lido will determine the re+ared staff actions and assign responsibility to NRC offices as appropriate. Once approved, the staff actions will be forwarded as an enclosure to a memorandum issued by the EDO, Esample staff actions are provided in Exhibit 5 3.
5.10 S.tafLActiOILS.littullkWElidt The lido staff actions memorandum will require each responsible office / region to provide an action plan within 90 days and 6 month status reports to the EDO with a copy to the Director, AEOD and Chief, DEllil, on the disposition of staff actions. The Director, AEOD, will provide to the EDO a status report of all open llT staff actions, and will compile this 56
_ ~ -.,
i
)
i information in the AEOD annual re[mrt. In addition, closure report (r) will be prepared by the AEOD staff w identify actions taken to resolve each action item. Thh will normally be prepared as soon as practical after actions aie resolved, l
S.I1 Sthedule f
The llT shall parpare and transmit its final report to the Commission and the EDO in about 45 days from the time the team is activated, unless the EDO grants an estension of the l
schedule. The EDO will normally schedule a meeting approximately one week after the l
Advance Copy has been distributed for the llT to brief the Commission on its investigation.
The following writing / editing schedule provides guidance to ensure that the report is finished on time.
nay Acthty 1 14
-Team's onsite investigation.
15 32 Team members prepare their individual draft sections incitiding findings and conclusions.
i Members prepare draft figures and select photographs during this period to give i
Graphics adequate preparation time..
j Authors /IIT leader review and revise drafts.
33 41 The team assembles an essentially complete draft of the report for each 61 ember to l
review. The Directer, AEOD, should be given this draft for information and review. -(The purpose of the AEOD review is to provide suggestions to the llT leader concerning the completeness of the report.)
i Following.his review, the team meets to discuss comments on each section and revise the draft as necessary.
l The tditor reviews each section.
The authors review the editor's comments and resolve problems.
The llT leader extracts fmdings and conclusions into a separate section, but leaves findings and conclusions in text.
The Director, ABOD, and the !!T leader discuss suggested followup staff actions.
- 17 Leader Function / Direct input 57 l
-._.._.-,-._.____.._...,._..._._.-_._.__.__._.,.__.-_.,...-....J
The team meets to resohe team and Al!OD comments. The llT leader determines which AEOD comnients to incorixitate into the report.
The llT leader (with the Director of AEOD) briefs the !!DO on findings and 42 conclusions.
43 The team makes final review of the complete draft for typos. consistency, and errors, and reviews findings / conclusions for accuracy and consistency. Team members review the same draft (i.e., review sections in series).
ihe final draft is tiut into single-space format.
The !!T le. der and editor review the final text, resohe tytes, etc. and the llT leader prepares a transmittal memorandum.
All team members should concur on the report and on the transmittal filemorandurn.
The editor and ilT leader assemble the final version and have 25 copies of this 44 *
"Advancui Copy
- version reproduced for distribution.
45 51 Couriers deliser 25 Advance Copies to Commissioners and the UDO.
.i2 59' ilT presents itt, report to the Commission.11eproduce 75 copies for distribution by SECY to the commission hearing room for public availability during the Commission briefing.
Published NUllEG distributed to staff and public, The EDO will transmit a copy of the report to the licensee and staff for review and comment. Copics will also be sent to the PDit.
D; rector, AEOD, and IIT leader will prepare suggested followup staff actions for EDO consideration and review.
@75" The EDO will define and assign followup actions based on the llT report, comments received from the licensee and staff, and staff requirements memorandum from the Commission, and issue the lido staff actions to the appropriate NitC offices.
llT lxader Function / Direct input Need 1-2 week delay to receive licensee and Commission comments on report for EDO consideration.
58
5.12 binbib lishibit 51 Ban 1EltlkpurLOh11ine i
Abstract 11 List of 1;lgures and Tables til Ac.onyms IV The NitC Team for the (Facility Name) Event of (!! vent Date)
V llejort ik).iy 1.
FAECUTIYli SUMM Ally L
NAititATIVli OF Tilli INCIDENT 3.
SYSTliM i)ESCillPTIONS, PESPONSli, AND liVALU ATION 4,
llUMAN FACTORS CONSIDlillATIONS
SUMMARY
OF INCIDliNT PRiiCUltSORS AND llELATED OPl! RATING EXP6RIENCE 6.
SIGNIF1CANCli OF Tilli INCIDhiNT 7.
ADDITlONAL ISSUES 8.
FINDINGS AND CONCLUSIONS 8,1 Principal Findings and Conclusions 8.2 Other Findings and Conclusicas VI APPENDICES A:
ilT Charter II:
Description of Fact-Finding Efforts 1, investigative Methodology 2, Interviews and Meetings
- 3. Plant Data
- 4. Quarantined Equipment C:
Suppicmental Information 5-9
thhibit 5-2 IIT TeanLLeadCLChCChlill j
1:enort Preparation and Prestt11alicILlGilidtlint S l
1.
Assemble a draft report for team and AEOD review (18 days after return from site)
I 2.
Deve:ap proposed staff:tetions 3.
Technical editor review of report 4.
Brief EDO (28 days after return site) 5.
Final draft assembled (29 days after return site) 6.
Final version assembled and 25 advanced copies reproduced (30 days after return form site) 7.
Couriers deliver advanced copies to Commissioners and EDO (31-37 days after return from site) 8.
Present report to Commission (38-45 days after return from site) 75 copies of report to SECY for public availability during hearing 9.
Finalize input on followup staff actions for EDO consideration O
5-10
Exhibit 5-3 Jinnmle Staff Actiem STAFF ACTIONS RESULTING FROM Tile INVESTIGATION OF MARCil 20,1990 INCIDENT AT VOGTLll, UNIT 1
(
Reference:
NUREG-1410) 1.
Issue: Adequacy of Shutdown Risk Management
(
References:
Sections 3,7, 8 and 9 Findings 10.1,10.3,10.5 and 10.8, and Appendices F, G and K)
During plant shutdown, maintenance and surveillance activities can result in opening of the primary and/or containment systems, stoppage of the shutdown coo"ng system, disabling electrical systems and movement of heavy equipment within the plant.
Ilundreds of plant workers, including contractors, are generally involved. Since, there is an economic incentive for the utility to complete the outage work in an expeditious manner, many tasks are performed simultaneously. There is also a need to comply with applicable license conditions, including technical specifications. All of these activities may be referred to as the outage activities. There is limited NRC guidance on allowable plant configurations other than the license conditions and technical specification requirements.
Based on Vogtle and other recent events, there appears to be a need t'< develop further regulatory guidance to ensure adequate risk management during shutdown conditions.
This regulatory concept recognizes the need to operate from time to time during-shutdown with less than the usual barriers and safety systems. Ilowever, with proper licensee planning, it is believed that the outage should strive to conduct the otherwise more risk significant activities (e.g., mid loop) at a time when more barriers and systems are in place or operable. Such shutdown risk management does not currently appear to be practiced. While licensees should be responsible for shutdown risk management programs and their implementation, the NRC should develop some generally applicable safety principles.
RESPONSIBLli ACTION OFFICE CATFGDJE a.
Review existing regulatory NRR (RES Generic guidance related to shutdown risk as needed) control and issue such new guidance as may be needed, include in the assess-ment of shutdown risk manageroent:
normal and standby electrical 5-11
i Exhibit 5-3 (CentinunO RI!SPONSillt.li ACIl0N
__ OfBC11_.
CATEGlRX systems and sources, including switch-yard equipment; normal and alternate cooling systems; special alternate plans for loss of forced circula-tion; fission product barriers including primary and containment systems and special activi-ties such as movement of heavy kuds or construction activities.
b.
Continue to develop shutdown Ri!S Generic risk analysis methodology and review the effectiveness of alternate cooling methods for loss of forced circulation.
Issue new guidance as appropriate, c.
Review the present regulatory NRR Generic requirements such as standard technical specifications for shutdown conditions and rev:se as needed, based on the results for Action (a) above. Develop guidance regarding revision of docu-ments such as EOPs, accident manage-ment procedures and plant technical specifications as necessary, 2.
Issue: Adequacy of Control Over Switchyard Activities
(
References:
Section 5.3 and Finding 10.2)
Switchyard maintenance activities require movement of equipment into and through the switchyard, in some cases, these activities may require storage of equipme.it in the switchyard At Vogtle, equipment requiring servicing was stored in the switchyard. A fuel and lubricant truck servicing this equipment initiated the Vogtle ' cident. Administrative control of activities in the switchyard was not adequate to prevent the Vogtle incident.
Ilased on operating events, some industry guidance has been issued regarding events caused by lack of control of activities in swit0 yards.
O 5-12
j i
fishibit 5 3 (Continued) f Movement of the truck through the switchyard presented an additional harard because some of the truck's contents were flammable. The Vogtle event potentially could have been more severe had an explosion of the flammable material on the truck occurred Such an explosion could have caused a loss of nonsafety power further complicating event recovery.
RESPONSillLl!
ACILON OFFICE CATEGORY a.
Evaluate the adequacy of NRR (RES Generic existing regulatory guidance as needed) and requirements for the control of activities e.nd hazardous materials in switchyards and protected areas.
J Issue new guidance as necessary.
RESPONSillLii ACTION OFFICli CAIEGORY b.
Evaluate the corrective plant-Region 11 Plant specific specific actions taken at Vogtle to ensure adequate control of activities and hazar-dous materials in the switchyard, P
i 5-13
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APPENDlX A f orm NRC489 (1 76)
U. 5. NUCLEAR REGULATORY COMMISSION NRC MANUAL l
T RANSMITTAL NOTICE 5
CHAPTER NRC-0513 NRC INCIDENT INVESTIGATION PROGRAM l
~I SUPERSEDED:
TRANSMITTED:
Number Date Number Date TN 0500 31 j
Chapter.
NRC-0513 8/6/87 Chapter NRC-0513 5/14/90 Page Page Appendix _ NRC-0513 8/5/87 AppendixNRC 0513 5/14/90 REMARKS:
This chapter and appendix are revised to incorporate EDO changes in response to the Inspector General's audit of the incident investigation Program and to make minor changes to reflect reorganizations.
I
-i i
W A-1
... -. -- -. - -.. -- ~. - -., -., -. -, - - -...
U.S. NUCLEAR REGULATORY C0HK!5510N l
NRC MANUAt O
volume:
0000 General Administration Part:
0500 Health and Safety AE00 CHAPTER 0513 NRC INCIDENT INVESTIGATION PROGRAM 0513-01 COVERAGE This chapter defines the scope, objectives, authorities, and responsibilities, and establishes the basic _ requiratents for the investigation of significant operational events involving reactor and non reactor facilities licensed by the NRC.
The Incident Investigation Program includes two invcstigatory initi-atives involving responses by either an Incident Investigation Team or the less formal Augmented Inspection Team f or certain saf ety-significant opera-tional evants.
The investigation begins af ter the f acility is placed in a safe, secure and stable condition, and, if applicable, af ter any incident re-sponse as defined in Chapter NRC-0502.
Operational events of lesser safety significance will continue to be reviewed and evaluated as described in NRC-0515.
0513-02 OBJECTIVES The overall goal of the Incident Investigation Program is to promote pub-lic health and safety and provide for the common defense and security by re*
O ducing the frequency of incidents and preventing accidents.
This goal is accomplished by ensuring tha*. the investigation of significant operational events is timelv, structured, coordinated, and formally administered; that a complete technical and regulatory understanding of such events is achieved; and that t'ie resultant findings are properly disposition >d.
The following objectives are designed to meet this goal:
021 Ensure that significant operational events are investigated in a manner that is tirnely, objective, systematic, and technically sound; that f ac-tual inf ormation pertaining to the events is documented; and that probable cause(s) are ascertained.
022 Increase the etfectiveness of NRC regulatory programs and licensee operations by the prornpt dissemination of the facts, conditions, circumstances, and probable causes of significant operational events and the identification of appropriate followup action.
023 Improve regulatory oversight of licensee activities by uncovering f acts that could show whether the regulitory process prior to the event con-tributed directly to the cau>e or course of the event.
024 Ent,ure that llT findings reflecting the above matters are properly dispositioned.
Approved: May 14, 1990 A-3
N_RC 0513 03 NRC INC10!hi INVESi!GATION PROGRAM 0513 03 AESPONSIB!tlTIES AND AUTHORITIES 0.4 fhe Executive Director f or Operatio3 approvet. the investigation of st W f icant operational events by Incident Investigation Teams and is respon-sible for and ensures that followup actions are taken as a result of each investigation, as defined in Appendix 0513, Parts I and 11.
032 The Director, Of fice for Analysis and Evaluation of Operational Data, maintains responsibility for establishment and maintenance of NRC invest @a-
~
tory capability and for arranging for training of designated tearr members, as defined in Appendix 0513.
033 Other NRC Of fices have responsibilities for the locident Investiga-tion Program as defined in this chapter and appendix.
034 NRC staf f functions in the execution of the incident Investigation
~ cograrc as defined in NRC Appendix 0513, Parts !! and 111.
0513-04 DEFINITIONS Oil Incident InvestJ ation.
A formal process conducted for the purpose i
of accident prevention whicT includes the gathering and analysis of informa-tion; the determination of findings and triaking conclusions, including the determination of probable cause(s) concerning significant operational events; and dissemination of the investigation re',ults f or NRC, industry, and public review.
042 Incioent In.'estigation Team _(!!T).
A group of technical experts who do not and have not had previous significant involvement with licensing and inspection activities at the af fected f acility and who perforto the single NRC incident investigation of significant operational events as defined in Appen-dix 0513, Part 11.
The IIT is led by a senior NRC manager.
Each lli reports directly to the Executive Director for 4* rations and is independent of Re-gional and Headquarters Office management.
043 AugmentedInspectionTeamjAlT).
A group of Regional technical experts augmented by pe rsonnel from Headquarters or other
- Regions, that performs incident inspections as defined in Appendix 0513, Part 111.
Itt rnenters may have had prior involvenent with licensing and inspection activities at the affected facility.
The AIT reports directly to the Regional Administrator.
044 _Sj3nificantOperationalEvent.
Any radiologidal, safeguards or other safety related operatlonal event at an NRC-licensed f acility which, by its comequences, poses an actual or potential hazard to public health and safety, property, or the environment.
A Significant Operational Event may also be referred to as an Incident.
The inve*tigatory response is defined by the potential safety significance of the event. the nature and comp'exity of the event, and the potential generic safety implications of the event.
The levels of investigatory responses are defined as follows:
^
Approved: May 14, 1990
\\
NRC INC10 TNT INVESTICATION PROGRAM NRC 0513 044.a a.
An IIT performs the single NRC investigation of significant opera-d tional events which may include one or more of the following characteristics:
(1) A significant radiological release, a major release of gradium recovery byproduct material to unrestricted areas, or personnel overexposure.
(2) Plant operation that exceeded, or was not included in, the design bases of the facility.
(3) Appears to involve a major deficiency in design, construction, or operation having potential generic safety implications.
(4) An event that led to a site area emergency.
(5). A safety limit of the licensee's Technical $pecifications was exceeded.
(6) A signi14 cant loss of integrity of the fuel, the primary coolant pressure boundary, or thr primary containment boundary of a nuclear reactor.
(7) Loss of a safety function or multiple failures in systems used to mitigate an actJal event.
(8) An event that is suf ficiently complex, unique, or not under-D stood to warrant an indeptadent investigation, or an event which warrants an investigation, such as an event involving safeguards concerns to best serve the needs and interests of the Commission, b.
An Ali performs inspections of events of lesser safety or safe-guards significance.
Events whose facts, conditions, circumstances, and probable cause(s) would contribute to the regulatory and tech-nical understanding of a generic safety concern or an important les-son of experience wl11 be assessed by an AIT.
The characteristics of these events may include one or more of the following:
(1) Multiple failures in safety-related systems.
(2) Possible adverse generic implications.
(3) Are considered to be complicated and the probable causes are unknown or difficult to understand.
l (4)
Involve significant system interactions.
l (5) Repetithe failures or events involving safety-related equipment or deficiencies in operations.
i (6)
Involve questions / concerns pertaining to either licensee opera-k tional or managerial performance.
l A-5 App vved: May 14, 1990
NRC 051,3 0$
NRC INC10fNV lNVIS1!GAVION PROGRAM 0513 05 BA$1C REQUIREMENTS 051 Aplicability.
The provisions of this chapter and its appendix apply to th'e Tei3 quarters and Pegional Of fices of NRC.
052 Appendix 0513.
Defines the major components of the incident Investi-gation Progron (i.e.,
incident investigation and augmented inspection).
a.
Appendix 05134' Part 1, INCIDENT INVt$11GA110N PROGRAM.
Establishes respordIb~iTTtieT and Gnctions f or 'hE7ffTceT foT tr,cident inves-tigation; defines objectives and authoritiet; and provides general guidatice, b.
Appendix 0513, Part_i_l, INCIDEN1_lNV[$11 GAT 10N TEAMS.
Outlines In-cident Investigation Team (IIT) response, objec[Ives, and author-ities; provides guidance for develop;oent of procedures; and estab-lishes followup responsibilities.
c.
Appendix 0513, Part 111, AUGHENif 0 INSPECTION TEAMS.
Outlines Aug-mented Inspection Team TKIT) response, oblectives, and authorities, and provides general guidance.
O O
A4 Approved: May 14, 1990
NRC INCIDENT INVEST!GATION PROGRAM NRC Appendix 0513 O
PART I INCIDENT INVf STIGAT10N PROGRAM A.
COVERAGE This part defines the responsibilities and functions of the various Of fices of NRC in establishing and implementing !!Ts and Alis, B.
DUTIES 1.
The Executive Director for Operations (EDO):
a.
Determines whether a potentially significant operational event is to be investigated by an Incident Investigation Team (11T)
(See Appendix 0513, Part II).
b.
Selects the gli leader and team members, provides policy and technical direction, and ensures the independence of the Inci-dent Investigation Team.
2.
The Director, Office for Analysis and tvaluation of Operational Data:
a.
Administers the incident Investigation Program to meet the objectives set forth in this chapter, with the assistance of other NRC Offices, b.
Assures that procedures governing 11Ts are developed, coordi-nated, approved, distributed, and maintained.
c.
Identifies and provides staff to be members and leaders of IITs and Alis, d.
Provides administrative support to !!Ts necessary to achieve objectives defined in Appendix 0513, Part II, with assistance from other NRC Offices, e.
For events which warrant at least an AIT response, consults with the Regional Administrator and the Director of NRR or HMSS to decide if an AIT or Ili response is appropriate.
Identifies the potential safety issues and provides recommen-dations to the EDO on events warranting an IIT response.
Establishes and maintains rosters of potential team leaders and team members who are certified in incident investigation via formal training, and makes recommendations to the E00 concern-ing IIT composition.
L g.
Identifies needed training and coordinates training require-ments for IIT candidates through its Technical Training Center.
A-7 i
L Approved: Pay 14, 1990 I
NRC Appendix 0513 Part 1 NRC INCIDENT INVEsilGATION PROGR.A.M.
h, Assesses the ef fectiveness of the Incident Investigation Pro-gram activitier, and recomends action, as appropriate, to in-prove the program.
3, TheDiector Office of Nuclear Reactor Regulation; 2
a.
Assures that procedures governing Alls are defined, developed, coordinated, approved, distributt'd, and maintained, b.
Identifies and provides staf f to be members and leaders of IITt.
and AITs.
Provides assistance in implementing the Incident Investigation c.
- Program, d.
Recomends to and coordinateb with the appropriate Regional Adriinistrator on events which may warrant an Ali as defined in Appendix 0513, Part !!!,
e.
For events which warrant at least an Ali response, consults with the Regional Administrator and the Director of AE00 to decide if an AIT or lli response is appropriate.
Identifies the potential reactor safety or reactor safeguards issues and provides recommendations to the EDO on events warranting an lli response, including IIT composition.
4.
The Director, Office of Nuclear Material Safety and Safegu,ards:
a.
Identifies and provides staf f to be members and leaders of IITs and AITs.
b.
Provides assistance in implementing the NRC Incident Investi-gation Program, c.
Recommends to and coordinates with the appropriate Regional Administrator on events which may warrant an AIT as defined in Appendix 0513, Part 111.
d.
For events which warrant at least an AIT response, consults with the Regional Administrator and the Director of AE00 to decide if an AIT or Ili response is appropriate.
Identifies the potential non reactor safety or safeguards issues and provides recommendations to the EDO on events warranting an i
llT response, including the lli composition.
5.
The__ Director Office of_ Administration l
a Provides staf f to assist IIIs in writing, editing, word precessing, and publication of reports through the Division of freedom of Information and Pub 1' cations Services.
A-B Approved: May 14, 1990 1
l
NRC Appendix 0$13 NRC INCIDENT INVESTIGATION PROGRAM Part 1 6.
The Diractor, Office of Personnel:
Assists the Technical Training Center with IIT training on an as-needed basis.
7.
_ Regional Administrators:
a.
In coot-dination with NRR or KMSS. determine those operational events warranting investigation by an AIT and as soon as it becomes clear that at least an AIT is warranted-preterally before an Ali is actually established--consult with the Direc-tors, NRR or HMSS, and AEOD, to consider whether an IIT response is appropriate. Identify the potential safety issues and provide reconnendations to the E00 on events warranting an IIT response, including the IIT composition, b.
Select the AIT leader and team merttaers and direct, coordinate, and approve the performance of AITs.
c Provide assistance in implementing the NRC Incident Investiga-tion Program.
d.
Identify and provide staf f to be members and leaders of !!Ts and AITs.
O e.
For all IITs and some AITs, issue a Confirmatory Action Letter, as appropriate, to the af fected licensee requiring that, within the constraints of ensuring plant safety, relevant failed equip-ment is quarantined and subject to agreed-upon controls for troubleshooting; that information and data related to the event are protected; and that the plant is maintained in a safe shut-down condition until concurrence is received f rom the NRC to restart.
8.
Director, Of fice of Governmer.tal and Public Aff airs:
a.
Fol'iows established NRC public information policies for release of information related to NRC investigatory responses to oper-ational events (see Appendix C513, Parts !! and Ill).
P omotes the NRC policy of encouraging licensees to take the li sd in iuormation dissemination activities related to incident
'trestigations at their facilities, c.
Identifies and provides staff to support IITs.
9, p.e Director, Of fice of Nuclear Regulatory Research:
a.
Identifies and provides staf f to be members and leaders of IITs and ".1<
A-9 Nsproved: May 14, 1990
NRC Appendix 0513 Part 1 NRc INCIDENT INVESTIGATION PROGRAM b.
Provides assistance in implementing the NRC Incident invastiga-tion Program.
10.
The Office of the General Count,el:
a.
Provides assistance in isnplementing the NRC Incident Investiga-tion Progran, b.
Identifies and provides staff to support 11Ts.
O 9
Approved: May 14, 1990
NRC INCIDENT INVESTIGATION PROGRAM NRC Appendix 0$13 PART !!
INCIDENT INVESTIGATION TEAHS This Part defines the investigatory initiative involving a response by an Inci-dent investigation Team (IIT).
A.
OBJECTIVES Of INCIDENT INVESTIGATION TEAM l
Conduct a timely, thorough, systematic, formal, and independent investigation of certain safety-significant events occurring at facilities licensed by the NRC.
Collect, analyze, and document factual information and evidence sufficient to determine the probable cause(s), conditions, and circumstances pertaining to the event.
B.
SCOPE OF INCIDENT INVESTIGATION The investigation performed by an IIT emphasizes f actfinding and determination of probable cause for a significant operational event (as defined in this chap-ter).
The scope of the investigation is sufficient to ensure that the event is clearly understood, the-relevant facts and circumstarces are identified and collected, and the probable cause(s) and contributing cause(s). are identified and substantiated by the evidence associated with tSe event.
The investiga-ion shall consider whether licensee and NRC activi'.ies preceding and contri-Os uting to the event were timely and adequate.
- It is expected that the scope of an llT will include conditions preceding the event, event chronology, systems
- response, human factnrs considerations, equipment performance, precursors to the event, emergency response, safety significance, radiological considerations, and findings and conclusions.
The scope of the investigation does not include:
1.
Specific assessment of violations of NRC rules and requirements; or 2.
Review of the design and licensing bases for the f acility except as necessary to assess the cause for the event under investigation.
C.
SCHEDULE The IIT shall be activated as soon as practicable after the safety significance of the operational event is determined and will begin its investigation as soon as practicable after the. facility has been placed in a safe, secure, and stable condition.- If there is an NRC incident response, the investigation will begin after it is deactivated.
The' IIT shall issue interim reporta at appropriate intervals outlining the sta-tus, plans, and relevant new information related to its investigation.
O A-11 Approved: May 14, 1990 M
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NRC Appendix 0513 Part !!
hRC INCIDENT INVESTIGATION PROGRAM The !!T shall prepare and transmit its final report to the Cortmission and 3
the ED0 in about 45 days from activation of the team, unless relief is granted i
by the EDO.
ibe EDO will normally schedule a ineeting approximately one weet af ter receipt of the final report for the lli to brief the Cortrission on its investigation.
Information containec in the report is nct to be released until a copy of the final report is placed in the Public Document Room (pDR),
which normally occurs during the day of the Corrnission briefing, if one is conducted, if deerned ne c e s sa ry, the EDO may forward a copy of the final report to the affected licensee before the Corrnis sion
- briefing, and simultaneous 1,y forward a copy of the final report to the PDR.
following the Cornission briefing, the EDO will transmit a copy of the final report to the licensee and NRC staf f f or review and corrnent prior to the EDO defining and assigning followup actions to NRC offices.
D.
TEAM COMP 0slT10N AND OUAllflCATIONS The !!T will te corrposeo of technical experts selected on the basis of their expertise, potential contributions to the event investigation, and their free dom from significant involvernent in the licensing and inspection of the f acility involved or other activities associated with issues that had a direct irnpact on the course or consequences of the event.
The nunber of nembers and areas of technical expertise required for each 111 will be determined based on the type of f acility and characteristics of the event.
The tearr leader and expert mer bers should, in general, be selected f ron, ros.
ters of candidates who have been certified through formal training in incident investigation.
The team 1(ader shall be a senior NLC rranager from the Senior Executive Service.
E.
DUTIES The llT carries out the single NRC f actfinding investigation of the event and is authorized and responsible to pursue all aspects of an event that are with-in its scope as defined above.
NRC response persor.nel on site shall provide support as needed to assure the ef ficient end eff ective transition to investi-gaticn of the event, 50 as not to interfere with plont saf ety.
The folloning duties are in addi;.on to the duties defined in this chapter and appendix.
1.
The Executive Director for Operations:
a.
Approves the need for, establishes, and provides policy 6nd technical directions to the llT.
b.
Determines that the investi ation wbs ef fectively conducted and g
consistent with the goals of the incident Investigation progrer:.
c.
Assigns follcxup actions associated with the 117 report.
d.
Determines appropriate n.tthod of i ride pe n den t assesu ent for followup artiens, depnding upon the nature e rid s ig n i f ic a rn e of the IIT findings.
A.12
,,.s 3r
l NRC Appendix 0513 i
NRC INCIDENT INVESTIGATION PROGRAM Part !!
i 2.
HeDirector.Officefor_ Analysis _andEvaluation_ofOperationalDatj:
a.
Provides adminis'.tlve support to the 117 by assisting the Team to meet its objectives and schedule.
b.
Provides advice and consultation to 11T leader on procedural t
matters and suggestions regarding completeness of 11T report.
c.
Coordinates with
- Director, Office of Administration, to provide support necessary to publish an IIT report as a NUREG document, d.
Prepares a single report identifying the resolution of all !!T findings which require followup action.
3.
Reatonal Administrators:
a.
Provide assistance in briefing and providing background infor-mation to the !!T when it arrives on site, b.
Provide onsite support for the llT during its investigation, c.
Identify and provide staff to monitor licensee troubleshooting activities to-assess equipment performance.
4.
IIT Leader:
a.
Directs and manages the 111 in its investigation and assures that the objectives and schedules are met for the investiga-tion as defined in this chapter and appendix, b.
Identifies adds, and removes equipment from the quarantined list withIn the constraints of ensuring plant safety and equipment testing and maintenance requirements, and determin-ing causes for equipment anomalies.
c.
Serves as principal spokesperson for the !!T activities in interacting with the licensee, NRC Offices, ACRS, news media, and other organizations on matters involving the investigation.
d.
Prepares f rec uent status reports documenting IIT activities,
- plans, significant findings, and safety cencerns that may require timely remedial actions, or issuance of Information Notices, Bulletins, or Orders, e.
Receives direction and supervision from the Executive Direc-tor for_ Operations, f.
Identifies and requests that the EDO provide additional IIT-resources _(e.g.,
additional members, consultants, contractor f-~
assistance) as needed.
A-13 Approved: May 14, 1990
NRC Appendix OH3 Part II NRC]NC10EN_TINVf571GATJpLPj0GR.A$
g.
Identifies and recoraends to the E:'; the need for further studies and investigations, such as staf f performance in regu-latory activities prior to the event, when significant concerns could not be thoroughly evaluated because of time or resource limitations.
h.
Ensures, in cooperation with the Ili team members and the technical writer / editor, preparation of the final report within the due date established by the EDO.
F.
CONDUCT Of INVE511 GAT]QN The investigation process is based on the principles of incident investigation provided in IIT training prr. grams and described in lli procedures.
1.
The team composition of the lli shell be structured and the proce-dures developed to maintain independence and objectivity.
Person 101 possessing a high degree of independence, ingenuity, and resource-fulness should be selected to assure P st the investigation is con-ducted in a timely, professional, thorough, and coordinated manner.
2.
Implementinj Procedures.
rrocedurch to guide and control the es-tablishmiiit adiiTnvestigatory activities of an lli are to be included in an investigation manual.
At a minimum, the following procedures shall be developed by the Of fic a for Analysis and Evaluation of Op-erational Data:
a.
A procedure for activating an Ili including respohsibilities, coordination, communication, team composition, and guidance, b.
A procedure for IIT investigation of an operational event in-ciuding responsibilities, work plan, communication, interfaces, scope, and schedule, c.
A procedure for interviewing pe.sonnel, d.
A procedure for collecting and maintaining records, documents, data, and other information, e.
A proced'.'re for treatment of quarantined equipment.
f.
A procedurc for preparation, release, and distribution of the Ili report and related documents, g.
A procedure defining administrative support requirements for an III.
Procedures and guidance for the conduct of investigative activities of an llT are provided in NUREG-1303, " Incident Investigation Manual."
O A-14 Approved: May 14, 1990
NRC Appendix 0513 Part !!
- RC INC10FMT INVEST 3110N PROGRAM G.
FOLLOWP ACTION $
following HR0 staf f and licensee review and comment on the IIT report, the EDO shall identify and assign NRC Office responsibility for generic and plant-specific actions resulting from the investigation that are safety significant and warrant additional attention or action.
Of fice Directors shall provide a written status report on the disposition of each assigned action as directed by the EDO, The memorandus assigning followup actions should address all lli findings, including those which are judged to require no followup action, in order to document the consideration of all findings.
The resolution of plant specific items will be documented in a single Safety Evaluation Report and each generic item will be individually tracked via the ED0's Work Item Tracking System (WITS).
In addition, a single closecut report will be prepared by the Of fice of AEOD with input from other of fices to identify the resolution of each finding.
Each resolution of an !!T finding will be subject to independent assessment as to its adequacy and completeness.
The EDO will decide on the appropriate method of independent assessment, depending upon the nature and significance o' the finding.
O t'
O A-15 Approved:
May 14, 1990
NRC 1NCIDENT TNVESTIGATION PROGRAM NR; Appendix 0513 PART Ill AUGMENTED INSPECTION TEAMS This Part defines the inspection initiative involving a response by an Augment-ad Inspection Team (AIT).
A.
OBJECTIVES OF AUGMENTED INSPECTION TEAM:
Conduct a ;imely thorough and systematic inspection related to significant op-erational events at %ilities licensed by the NRC.
Assess the inity significance of the event and communicate ;o Pegional and Headvarters unagement the facts and sifety conrurns related to the event such that ap; Npriate follwup actions can be taken (e.g., study a generic concern, issue an Information Notice or Pu11etin).
Collect, analyze, and document f actual information and evidence sufficient to determine the cause(s), conditions, and circumstances perteining to the event.
B.
SCOPE OF AUGMENTED INSPECTION The AIT response should emphasize f act-finding and determination of probable cause(s) and should be limited u issues directly related to the event.
The All response should be sufficiently broad and detailed to ensure that the event and related issuer are well defined, the relevant facts and circumstances are identified and collected, and the findings and conclusions are identified and substantiated by the information and evidence asso:iated with the event.
The inspection should consider the adequacy of the licensee actions during the event.
The scope of the inspection shall be defined and revised, as appropriate, by the Regional Administrator directing the AIT inspection.
C.
SCHEDULE The AIT shall be activated as soon as r--ticable after the safety significance of the event is determined and sho' W ' its inspection as soon as practic-able af ter the f acility has been ).ated a a safe, secure, and stable condi-tion.
The AIT shall prepare and transmit its report to the Regional Administrator within 30 days from activation, unless relief is granted by the Regional Administrator.
D.
7EAM COMPOSITION AND QUALIFICATIONS The AIT will be composed of technical experts from the responsible Regional Office, augmented by personrel from Headquarters or other Regions with spe-cir technical qualificat'ons to complement the technical expertise of the Regio al response.
The size of the AIT snd the areas of expertise will be A-16 Approved: May 14, 1990
NRC Appendix 0513 Part III NRC INCIDENT INVESTIGATION PROGRAM iV determined by the Regional Administrator and coordinated with other NRC Offices based on the event and its implications.
The AIT Leader will normally be selected f rom the respo_nsible Regional Office unless lead is transferred to another NRC Of fice by mutual consent through a Task Interface Agreement.
E.
DUTIES The AIT is authorized and responsible to pursue oli pertinent aspects of an operational event.
The following duties of NRC offices are in addition to those defined in this chapter and appendix.
1.
The Director, Office of Nuclear Reactor Regulation:
a.
Monitors and evalutes the AIT process and products, and as-sures that AIT procedures are properly maintained.
b.
- Defines, deve'opr, coordinates, approves, and maintains the necessar,v proceaures to guide an. control AIT activitirs.
2.
Regional Administrators:
a.
Ste.f f, direct, supervise, coordinate, and approve the perfor-p of AITs.
t...o e
Q b.
.t that the AIT response is initiated, defined, and conduct-9.. manner that achieves the objectives.
c.
h6M ' if and when the AIT inspection should be upgraded to i
ar. T IT and, in consultation with the Director of NRR or HMSS, as
- 00, recommemi to the E00 that un IIT response is war-ranted.
d.
Provide administrative support and resources to AITs in ar.sist-ing the AIT to meet its objectives and schedule, e.
Issue a pt riodic Oaily Staf f Note to the EDO when an AIT re-sponse is plemented and provide upates as appropriate.
f.
Ident" request additional expertise for AIT response from othet
' ices, g.
Identi,
idllewup actions needed based on the AIT findings.
h.
The duties defined in this part for a specific AIT may be transferred to another NRC office by mutual consent through a Task Interface Agreement.
l 3.
The AIT_ Leader:
a.
Manages the AIT in its inspection snd assures that the objec-tives and schedules are met for the inspection as defined in this chapter and appendix, A-17 Approved: May 14, 1990
NRC Appendix 0513
.NRC INCIDENT INVESTIGATION PROGRAM Part III b.
With the approval of the Regional Administrator, adds and re-moves equipment from a quarantined list (if applicable) within the constraints of ensuring plant safety, determining causes for equipment anomalies, and testing and maintenance considerations, c.
Serves as principal.spokesperson for AIT activities in interact-ing with the licensee, NRC Offices, ACRS, news media, and other organizations on matters involving the inspection, d.
Prepares interim status reports documenting AIT activities, plans, and new information.
Communicates to NRC of fices any significant findings and safety concerns that may require timely remecial actions, or issuance of Information Notices, Bulletins, or Orders.
e.
Receives direction and supervision from the Regional Administrator.
F.
AIT IMPLEMENTING PROCEDURES At a minimum, the following AIT implementing procedures shall be prepared by the Office of Nuclear Reactor Regulation and included in the investigation manual:
1.
A procedure for activating an AIT including responsibilities, coordi-nation, communication, and guidance.
2.
A procedure for AIT investigation of an operational event including responsibilities, communication, interfaces, scope, and schedule.
Procedures and guidance for the conduct of inspection activities of an AIT are provided in NRC Inspection Manual Cnapter 0325, " Augmented Inspection Team" and in Inspection Procedure
- 93800,
" Augmented Inspection Team Imple-menting Procedure."
G.
FOLLOWUP Identification, review and approval of licensee corrective actions, licensee ac-tions prior to restart, and NRC enforcement actions shall be through the nor-mal organizational structure and procedures.
The Regional Administrator will initiate followup actions needed based on the AIT findings.
Generally, followup actions will be handled through normal office procedures.
For example, the Regional Office might initiate a Task Interface Agreement with the Office of Nuclear Reactor Regulation to examine a particular issue and track the issue on the Region's open item list.
Specific guidance on resolution and closeout of followup actions will be provided in the Inspection Manual and Inspection Procedures.
O A-18 Approved: May 14, 1990
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NRC INSPECTION-MANUAL DEAB MANUAL CHAPTER 0325 l
AUGMENTED INSPECTION TEAM 0325-01 PURPOSE The purpose of this manual chapter is to incorporate.into the NRC inspection program the existing Augmented Inspection Team (AIT) basis and-philosophy, currently in NRC Manual Chapter 0513.
NRC Manual Chapter 0513, "NRC Incident t
Investigation Program " defines the authorities, responsibilities, and basic requirements for personnel investigating significant operational events, and characterizes the differences between an AIT and an incident Investigation Team (llT).
0325-02 OBJECTIVES To establ_ish ' policy providing for the timely, thorough, and systematic _ in-spection of significant operational events by an AIT, The purpose of an Ali is to determine the cause(s), conditions, and circumstances relevant to an-event and to communicate its findings, safety concerns and recommendations to NRC management.
This manual-chapter addresses the following areas:
a.
Authorities, responsibilities, and' duties pertaining to activating the Ali, conducting the inspection. and ensuring that inspection _ findings are properly addressed, b.
Guidance on selecting operational events for AIT inspections..
c.
Guidance on. scheduling the conduct of AIT inspections.
-d.
Team composition and qualifications.
0325-03
-AIT ACTIVATION - AVThvRITIES AND RESPONSIBILITIES 03.01 Executive Director for Operations (EDO) a.
Resolves conflicts betwcen a Regional-Office and/or one or more Pro-gram Offices regarding such-matters --as the need to initiate an AIT,
-- the Office assigned lead responsibility for. AIT implementation, and -
--Office representation on an AIT.
Issue Date:
04/18/91
-.2 a
b.
May upgrade the inspection response from A1T status to lli status any time circumstances warrant the upgrade.
03.02 Regional Administrator (or Designee) a.
Determines which operational events warrant an AIT response.
This decision is to be coordinated with NRR and NMSS.
Deliberations may include considering the appropriateness of other less formal respons-es, such as a special regional inspection or an in-depth licensee investigation, in lieu of an Ali, b.
Determines if a higher level of response (i.e., an !!T) would be nore appropriate, in consultation with Directors of NRR atid/or NMSS, and AE00.
This consultation should occur when it becomes clear that at least an AIT response is warrsnted, but preferably bef ore the AIT is actually activated, c.
Notifies, as appropriate, the Deputy Executive Director for Nuclear Reactor Regulation, Regional Oper9tions and Research (DEDR) and/or the Deputy Executive Director for NL ' ar Materials Safety, Safeguards and Operations Support (DEDS) when
- Jecision has been made to implement an AIT response, d.
Selects the A!T leader (normally from the af fected Regional Office) and the team members.
Team members may be chosen at large from the NRC staff to obtain the correct technical expertise.
However, it is not necessary that each Office be represented on the AIT.
In fact, the AIT may be composed of only regional inspectors, e.
Ensures that regional AIT selectees are relieved of all other assign-ments while serving as AIT members, f.
Prepares a written charter for the AIT delineating the scope of the inspection; limits the scope to issues closely related to the event.
The written charter shall include the basis 'or the formation of the AIT.
Obtains headquarters' views oa +he appropriateness of the AIT charter from the plant project Manager, who confers with the Division of Operational Events Assessment, NRR.
g.
May transfer lead responsibility for AIT implementation to another Office, by mutual consent, through a Task interface Agreement.
h.
Considers issuance of a -Confirmatory Action Letter (CAL) to the af-fected licensee depending on the circumstances of the event end, as necessary, supports tb AIT by coordir ering the disposition of CAL commitments with the licensee.
The ccns,derations for issuante of a CAL, and for its content, should include whether equipment that has
-failed at misoperated should be quarantined and be subjected to agreed upon controls (insofar as such controls would not interfere with the need to observe operational safety rec,uirements).
If a CAL is deemed necessary, the locident Investigation Manual, NUREG 1303, provides ample guidance on the purpose, scope and format of a Confirmatory Action Letter, i.
Reports in the Daily Staff Notes to the EDO when an AIT response has been implemented.
B-2 1ssue Date: 04/18/91 0325
03.03 Program Office Directors (or Designees) p a.
Identify and provide staf f to serve as team members and leaders and t
ensure that the administrative support necessary to dispatch AIT mem.
\\
bers in a timely manner is in place.
Ensure that AIT selectees are relieved of all other assignments while serving as AIT members, c.
Confer with the Regional Administrator (or designee) and with the Director of. AE00 (or designees) about whether an operational event warrants response by an A1T or an llT.
Coordinate the AIT activation and inspection effort (which includes conferring with the Regiona'l Administrator (or designee) on the appropriateness of the MT charter), and initiate the followup action needed, based on the findings of the AIT report, when lead responsi-bility for Ali implementation is transferred to the Office.
May issue an Order to Show Cause (Order) if the licensee and Regional Of fice cannot agree on th(.erms of a CAL, i.e., those actions the NRC believes the licensee should take following an event, or if it is deemed appropriate subsequent to the issuance of a CAL to reaffirm the licensee's commitments.
(The incident Investigation Manual, NUREG 1303, provides additional guidance on the purpose, scope, and format of an-Order).
O f.
Review the A1T report for generic safety implications and initiate V
followup action and tracking of the issues on a multiplant basis, as appropriate.
Document the results of the review, even if followup action is not needed.
(NRR,NMSS) 0325-04 CONDUCTING THE AIT INSPECTION - AUTHORITIES AND RESP 0MlBILITIES 04.01 Regional Administrator (or Designee) a.
May revise the scope of the AIT charter during the inspection, as l
deemed necessary, b.
Provides the team leader with an estimate of the duration of the AIT i
ir. pection phase (normally less than one week) and when the All report L
should be issued to th? Regional Administrator (every effort should be l-made to -accomplish this within 2 weeks af ter the onsite inspection effort is completed, but up to 3 weeks (or longer) is permissable if circumstances warrant),
c.
Advises the EDO and Directors, NRR, NMSS and AE00 of changes in the circumstances surrounding the inspection of an event that may warrant elevating the inspection to an llT response, d.
Determines need for inspection support from other Offices (such as the Office of Investigations) and consultants.
l (O l
e.
Provides administrative help, as required, to support the AIT and
")
facilitate the preparation of the AIT report.
B-3 l.
I 0325 issue Date: 04/18/91
f.
May handle inquiries by the media, public, Government, or headquarters personnel concerning the status of the AIT inspection.
9 Ensures that the AIT report distribution list includes the Executive Director for Operations (EDO), Advisory Committee on Reactor Safe. R guards (ACRS),theCommissioners,and within headquarters, the plant R Project Manager, the Document Control Desk (Office of Information Resources Management), and the Chief, Events Assessment Branch, Divi-sion of Operational Events Assessment, h.
Initiates followup action needed based on the findings of the AIT report in accordance with the normal organizational structure and procedures. For example, a regional of fice may initiate a Task In-terface Agreement with NRR to examine a particular plant-specific issue, and then track the resolution of the issue by means of the regional open items list.
In addition, the Division of Operational Events Assessment, NRR, will review the Ali report for generic safety implications and initiate fellowup action and tracking of the issues on a multiplant basis, as appropriata, i.
Documents the disposition of the findings of the AIT report, e'ven if followup action it not needed.
04.02 Augmented Inspection Team ( AIT) Leader a.
Receives instructions from the Regional Administrator (or designee) on the scope and estimated schedule of the alt effort.
1.
Provides input on needed technical expertise (including consul-tants) and recommends team members, b.
Supervises the AIT inspection.
1.
Is responsible for conducting the inspection at the site, includ-ing organizing the inspection effort, and directing and supervis-ing the f act-finding activities of the team members.
The team members report directly to the team leader.
2.
Is responsible for the preparation of the alt report, and as circumstances warrant, may direct team members to remain together following the inspection to facilitate the preparation of the AIT report.
Team members are assigned to the AIT until released by the team leader.
c.
Is responsible for keeping NRC management informed of progress and signific6nt findings of the inspectinn.
Note:
Inspection Procedure 93800 is the implementing procedure for this manual chapter.
0325-05 SELECTION OF OPERATIONAL EVENTS FOR AIT RESPONSES 05.01 General Guidance a.
Candidates for AIT response are:
B-4 1ssue Date: 04/18/91 0325
L1, Events of lesser potential safety-significance than.those that satisfy the criteria for llT. activation (see NRC Manual Chapter 0513).
2.
Events whose. facts, conditions, circumstances, and probable caus-es would contribute to the understanding of a generic-safety concerr, or some other important lesson related to the specific
- event, 05.02 ' et Characteristics.
An AIT response may result from an event at a
'facili
.ETncludes one or more of the following characteristics (partial-ly -excerpted from NRC Manual Chapter - 0513 "NRC incident investigation Progrhm"):
a.
Multiple failures in safety-related systems, b.
Possible adverse-generic implications, c.
Considered to be complicated and the probable cause is unknown or difficult to understand.
d.
Involves significant or unexpected system interactions, e.
Repetitive f ailures or events involving safety-related equipment or deficiencies in operations..
f, involves questions / concerns pertaining to either licensee operational or managerial performance.
9 Significant overexposures to radiation.
h.
-Significant radiation, releases of radioactivity, or radioactive-contamination.
05.03 Additional Guidance on Non-Reactor Events.. The following additional guidance (beyond that contained in.NRC Manual Chapter 0513), characterizes non-reactor events tnat may warrant the activation of an AIT:
a.--
Repeated instances of safeguards infractions that demonstrate the ineffectiveness of facility security provisions (guards or mechanical /electtonic surveillance).
-b.
Repeated instances of-inadequate nuclear material control and account-ing provisions to protect against theft or diversion of nuclear material.
c.
Failure of a mili tailings dam with.a substantial _ release of tailings material and solution off site, d.
Individual acute overexposures to radiation:
1.
Whole-body dose equivalent (external dcse or internal dose commitments) 5 rem 2.
Skin 30 rem 3.
Extremities 75 rem B-5 0325 Issue Date:
04/18/91 r
e.
Release of radiooctive material in concentrations chich, if overaged over a 24-hour period at the releast point, would exceed 500 times the i
limits specified in Appendix B, Table 11 of 10 CRf Part 20, f.
Such failure of radioactive material packaging that external radiation
{
1evels exceed 10 rads /hr or contamination of the packagiag exceeds 1000 times the applicable limits specified in 10 CFR fart 71.87, n
0325-06 SCHEDULE The Ali should be activated as soon as practical af ter the safety signifi-cance of the event is determined.
The team members should make every ef f ort i
to respond to an event within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. The team should begin its inspection as t'on as practicable aiter the f acility has been placed in a safe, secure, and stable condition.
0325-07 TEAM COMPOSITION AND QUAllflCATIONS 1
The AIT should be composed of experts from the responsible Regional Of fice, and may be augmented by personnel f rom Headquarters or other Regions with special technical qualifications to complement the technical expertise of the 4
Regional response.
The size of the AIT and the areas of expertise will be determined by the Regional Administrator and coordinated with other NRC Of-fices based on the event and its implications, I
END i
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I B - f, Issue Date: 04/18/91 0325
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,o mamry nuess 3 Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Conuuission Washington, DC 20555 9 VONh0H!Na OHGAN;i' A110N - NAML AND AOUAL SS Ut NRC. rf te - T vne as anove '; 6f corstr actar, pueth NHC Dw'.w Utb;crx R5e M o
US Nuctear Regulatory Cornmstic.n, and malng ac*ess 1 Same as 8. above 10 huPPLLiANI AH Y NOIES
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'lhe Incident Investigation Manual prescribes guidelines ior the conduct of investigative activities of the U.S.
Nuclear Regulatory Commission (NRC) Incident Investigation Teams (IlTs). The purpose of this manual is to provide llTs guidance to ensure that NRC investigations of significant events are timely, struct ured. coordinated, and formally administeredJihe guidelines are intended to assist the investigation rather than limit the initiatives and good judgment of the llTleader or membersflhe 11Tleader and team members should use their experience and those techniques that provide the mon confidence in assuring the IIT objectiv< s are achieved. These guidelines address IIT activation. conduct of the investigation, conducting interviews, tr a'.nent of quarantined equipment, preparation of the team report and followup of staff actions.
- 12. VIY WOnDSIDESCRIPTORS (ust words or pNases that will assist researer+rs in locatmg the rerat }
L3 AV AIL ADILITY ST ATEMENT Unlimited
- 14. SE CURITY CL ASSAC ATION Ine1 dent investigation Team (IIT) g m,,.yg incident Investigation Program (IIP)
.. U nclass.fied i
(t his lleport)
Unclassified
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ik NUMut H OF PAGth 16 PHsC L N40 FOAM 335 (2-89)
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