ML20098B069
| ML20098B069 | |
| Person / Time | |
|---|---|
| Site: | Grand Gulf  |
| Issue date: | 03/28/1984 |
| From: | Dircks W NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO) |
| To: | Palladino NRC COMMISSION (OCM) |
| Shared Package | |
| ML19272B132 | List: |
| References | |
| TASK-AE, TASK-P404 AEOD-P404, NUDOCS 8409250392 | |
| Download: ML20098B069 (6) | |
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e MEMORANDUM FOR:
Chairman Palladino Commissioner Gilinsky Commissioner Roberts Commissioner Asselstine Commissioner Bernthal FROM:
William J. Dircks Executive Director for Operations
SUBJECT:
LER DATA ON PERSONNEL ERRORS In response to the memorandum, S. J. Chilk to 'W. J. Dircks, dated March 2,1984,
Subject:
" Staff Requirement Briefing on Status of Grand Gulf," I am providing the following report dealing with operating experience at Grand Gulf.
Tnis report addresses the following two subjects which were available in preliminary form at the meeting:
1.
A count by plant of all LERs for events that_ occurr.ed.in 1983.
2.
A count by plant of all LERs reported in 1983 that included at least one personnel error.
[ Errors that were not attributable to the plant operating staff (i.e., construction errors, design errors, fabrication errors) were not included).
Two previous reports addressing similar aspects of operating experience at Grand Gulf are also enclosed.
The requested data, including comparable counts for'1981 and 1982, are provided in Enclosure 1.
AE0D obtained the data by searching the Sequence Coding and Search System (SCSS) for LERs submitted in 1983 and for LERs that stated or implied that a personnel error was involved in the event.
Because of the extensive amount of information from each LER that is coded in
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the SCSS, it was not necessary to rely on text searches for particular words (e.g., " personnel error") or to rely on the data coded by the licensee on the LER fom.
Thus, if the LER text expressly stated that a " personnel error" occurred, or if the LER impi.ied that a personnel error occurred (e.g.,
" Inadvertently he operated an. incorrect va.lve"), the iTfomation was coded into SCSS and was captured by the subsequent search.
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' Contact :
F.'J.
hbdon, AE0D
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I The Commissioners
- This data.is provided in response to the specific request.
However, the staff is concerned that the dats could be easily misinterpreted.
The plants included in Enclosure 1 viry considerably; for example, with respect to the numbe.r of years that they have been in operation.
Many of these plants have been in operation for several years and have completed the initial " debugging" phase when many equipment problems occur and procedural deficiencies are found.
Conversely, some plants (e.g., Grand Gulf) are still in this startup testing phase wher; large numbers of problems and errors are identified and reported.
To place the startup experience at Grand Gulf in better perspective, AEOD searched the~ SCSS data base for the total number of LERs and the number that contain at least one personnel error for plants in the startup phase of plant operation.
Specifically, AE00 obtained coents of LERs (Table 1) for several plants for the twelve months immediately following issuance of the Low Power Operating License.
TABLE 1 l
CPERATIONAL EXPERIENCE DURING THE TWELVE MONTHS
[
IMMEDIATELY FOLLOWING ISSUANCE OF A LOW POWER OPERATING LIC 4
Low Power Total Personnel
% Personnel Docket Facility Li cense LERs Error LERs*
Error LERs 416 Grand Gulf 6/16/82 256 86 34 387 Susquehanna 7/17/82 17 9 74 41 361 San Onofre 2 2/16/82 18 6-67 28 '
373 La Salle 4/17/82 187 67 28 369 McGui re 6/12/81 149 64 43 395 Summer 8/6/82 153 57 37 362 San Onofre 3 11/15/82 93 27 29 328 Sequoyah 2 6/25/81 65 26 40 i
The information presented here is based on information available to the staff and has not been verified with the individual licensees.
As indicated in Table 1 and Enclosure 1, Grand Gulf has submitted more LERs and reported more personnel errors than the other units.
Howev e'r Grand Gulf is the first BWR 6 in the country.
As such, there were no personn;el previously experienced in preparing procedures or operating this specific model reactor.
Even vendor personnel had minimum or no experience witn this type reactor.
As a result,' Grand Gulf may have been more susceptible to personnel errors than, i
for example, San Onofre 2 and 3 and Sequoyah 2 which are more standard in design.
In addition, Sequoyah 2 was the second unit started at that site in a short period.
Both San Onofre 3 and Sequoyah 2 had operating personnel with more directly applicab.le experience.
This may have contributed to fewer LERs.
In addition, care should be taken in reaching firm conclusions from this i
data.- Just as there is a risk of focusing too closely on individual events, a number of difficulties are associated with any collective analysis of LER data.
For example, when events are reduced to counts they lose their individual identity.
This hemogenization means all events are treated as if they were a
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which often is not the case.
Many of the errors reported by Grand Gulf, for example, were nisged surveillance requirements that did not directly affect plant operation.
' Finally, any variation which is due to factors other than differences Tn actual safety perfomance will give a spurious indication.of a problem.
For exanple, Region II has indicated that it has a low threshold for requiring licensees to report, and that this was particularly true for Grand Gulf.
Such variations.are discussed in detail in Appendix E or h0 REG-0572, " Review of Licensee Event Reports," which was prepared by the ACRS in 1979.
A copy of Appendix E to t;UREG.0572 was forwarded to the Commission.with my memorandum dated February 24, 1984.
Because of the many factors involved, an ' apparent trend or pattern in the data does not necessarily imply a real safety problem." Such an apparent trend or pattern requires study to detemine the underlying factors and to properly assess the implications and significance of the variations.
This in-depth analysis has not been done for the data provided in Table 1 and Region II has perfomed a review of the LERs issued during the period,
September 1, 1982 through September 30, 1983, for which personnel error was designated by the licensee as the root cause.
Region II found that none of the events had an affect on the. health and safety of the public, and the najority did not have the potential for resulting in an event which could have an affect on public health and safety.
In conclusion, while we have provided the requested LER count data, we believe that it is not appropriate and may in fact be nisleading to use raw LER counts in isolation as a relative or absolute measure of safety perfomance.
In addition, this practice has the undesired side effect of motivating licensees to minimize the number and content of LERs instead of sharing infomation for the benefit of all.
(SigneM/illiam J. Did; William J. Dircks Executive Director for Operations
Enclosures:
1.
LER Count Data For 1981-1983 2.
Grand Gulf Operating Experience 3.
Personnel Errors At Selected Operating Plants bec:
See Page 4 cc w/ enclosures:
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The Commissioners.
Distribution: w/ enclosure NRC PDR PTB CF e
PTB-SF AE00 SF F. Hebdon, PTB T. Ippolito, AEOD C. J. Heltemes, AEOD R. Dennig, PTB K. Seyfrit, ROAB K. Black, NAS H. Denton, NRR E. Case, NRR F. Miraglia, NRR D. Eisenhut, NRR R. DeYoung, IE J. Taylor, IE E. Rossi, IE G. Lanik, IE E. Jordan, IE M. Sinkule, RII J. Olshinski, RII
-J. O'Reilly, RII V. Stello, DEDROGR W. Dircks, EDO J. Roe, DEDO T. Rehm, A0/EDO
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LER Count Data For 1981-1983 Docket LERs Personnel Error. LERs Number Facility 1981 1982 1983 1981 1982 1985 29 Yankee Rowe 33 42 37 5
6 4
133 Humboldt Bay 5
8 1
1 1
1 155 Big Rock Point 27 35 14 3
6 3
206 San Onofre 1 29 26 5
13 11 3
213 Connecticut Yankee 19 10 18 4
3 1
219 Oyster Creek 72 61 19 22 23 9
220 Nine Mile Point 1 43 18-22 8
3 7
237 Dresden 2 75 53 61 22 12 12 244 Ginna 22 28 28 8
8 5
245 Millstone 1 -
39 32 28 5
6 4
247 Indian Point 2 33 49 37 4
4 3
249 Dresden 3
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33 44 36 4
6 8
250 Turkey Point 3 17 18 17 6
7 8
251 Turkey Point 4 17 14 15 2
6 6
254 Quad Cities 1 24 37 36 4
7 8-255 Palisades 53 49 69 13 11 10 259 Browns Ferry 1 83 S1 56 16 21 13 260 Browns Ferry 2 65 35 58 19 7
9 261 Robinson 2 33 18 27 15 6
4' 263 Monti cello -
24 15 8
6 4
3 265 Quad Cities 2 25 21 20 4
2 5
266 Point Beach 1 19 27 7
7 11 4
269 Oconee 1 25 20 18 9-9 9
270 Oconee~2 20 11 7
5 3
2 4
271 Vermont Yankee 36 26 24 5
4 7
272 Salem 1 118 88 45 24 21 17 275 Diablo Canyon 1 9
12 23 5
6 8
277 Peach Bottom 2 44 42 22 11 11 5
278 Peach Bottom 3 21 26 15 3
4 3
280 Surry 1 83 116 42 22 31 10 281 Surry 2 81 70 37 24 18 5
282 Prairie Island 1 18 13 5
8 6
3 285 Ft. Calhoun 1 11 20 8
1 4
2 286 Indian Point 3 -
10 4
5 2
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1
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287 Oconee 3 -
16 14 11 6
5 7
289 Three Mile Island 1 13 16 40 5
5 15 293 Pilgrim 1-58 54 52 13 20 10 295 Zion 1 51 50 45 17 10 12 296 Browns Ferry 3 71 51 50 8
11 6
298 Cooper 25 25 15 12 8
6 301 Point Beach 2 8
11 10 2
5 2
302 Crystal River 3 80 76 45 12 21 16 304 Zion 2 38 29 40 8
7 11 305 Kewaunee 38 35 25 12 5
7 306 Prairie Island 2 11 11 8
3 3
2 t
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Docket LERs Personnel Error LERs 1
Number Facility 1981 1982 1983 1981 1982 1983 309 Maine Yenkee 23 39 30 11 11 12 311 Salem 2 123 153 55 25 31 26 312 Rancho Seco 55 31 31 9
12 13 313 Arkansas Nuclear 1 14 30 24 5
9 5
315 Cook 1 64 107 101 18 43 26 316 Cook 2 70 109 104 13 33 29 317 Calvert Cliffs 1 84 82 54 17 24 14 318 Calvert Cliffs 2 57 54 58 9
14 15 320 Three Mile Island 2 32 34 46 13 8
15 321 Hatch 1 140 96 94 33 37 20 324 Brunswick 2 145 136 87 24 38 23 325 Brunswick 1 94 143 46 22 35 20 327 Sequoyah 1 133 77 85 37 16 17 '
328 Sequoyah 2 27 65 64 14 17 9
331 Arnold 49 81 39 14 18 7
333 Fitzpatrick 78 53 45 21 20 7
334 Beaver Valley 1 102 55 26 21 9
6 335 St. Lucie 1 60 70 26 11 13 7
336 Millstone 2 45 51 25 13 13 4
338 North Anna 1 87 88 70 20 19 13 339 North Anna 2 89 84 67 30 30 21 344 Trojan 31 22 15 13 11 9
346 Davis Besse 1 79 68 55 33 29 16 348 Farley 1 73 62 70 23 11 11 361 San Onofre 2 169 124 64 41 362 San Onofre 3 10 84 6
22 364 Farley 2 57 52 37 16 12 10 366 Hatch 2 133 135 117 31 50 29 368 Arkansas Nuclear 2 44 49 45 11 13 15 369 McGuire 1 187 82 100 78 37 32 -
370 McGuire 2 64 28 373 La Salle 1 151 116 52 36 387 Susquehanna 1 80 141 38 51 389 St. Lucie 2 63 18 395 Summer 65 123 28 38 409 Lacros se 15 20 7
5 6
4 416 Grand Gulf 1 181 162 57 60 e
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