ML20126E722

Forwards Response to NRC Re Weaknesses & Followup Items Noted in Insp Rept 50-305/92-21 of Annual Emergency Plan Exercise.Corrective Actions:More Mgt Involvement Will Be Provided & Emergency Plan Will Be Revised

ML20126E722
Person / Time
Site:	Kewaunee
Issue date:	12/28/1992
From:	Schrock C WISCONSIN PUBLIC SERVICE CORP.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
CON-NRC-92-159 NUDOCS 9212290284
Download: ML20126E722 (53)

Text

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WPSC I41414331598 , . NRC-92-159 TELECOPIER I4141433-5544 E ASYLINK 62891993 Et5c 055IS~EUBd C'SER Vidi~CUdP'O[ it'ON 600 North Adams

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• Green Bay.P." 'i4307 9002 December 28,1992 10 CFR 50.47 U.S. Nuclear Regulatory Commission ATfN: Document Control Desk Washington, D.C. 20555 Ladies / Gentlemen:

Docket 50-305 Operating License DPR-43 Kewaunee Nuclear Power Plant Response to NRC Inspection Report 50-305/92021, Annual Emergency Plan Exercise Evaluation

Reference:

1) Letter from C. E. Norelius (NRC) to C. A. Schrock (WPSC) dated October 28,1992, inspection Report No. 50-305/92021,

2) Letter from C. A. Schrock (WPSC) to Document Control Desk (NRC) dated November 16, 1992.

3) Letter from C. D. Pederson (NRC) to C. A. Schrock (WPSC) dated November 23,1992.

4) Presentation hlaterial for WPSC-NRC hianagement Conference, December 2,1992.

Reference 1 provided Wisconsin Public Service Corporation (WPSC) with the NRC's assessment of our annual emergency plan exercise. The inspection identified no violations of NRC requirements, however, several exercise weaknesses and follow-up items were noted particularly in the areas of command and control in the Technical Support Center and our ability to perform

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Page 2 an adequate self-critique. As requested by the NRC staff, a management meeting was held on -

December 2,1992, to discuss the identified weaknesses, our proposed corrective actions and'-

'I plans for a remedial demonstration.

in addition, the NRC staff requested that we provide a written response addressing each of the exercise weaknesses, This written response is being provided within 30 days of the management-- ,

meeting as was requested in Reference 2 and approved by the NRC in Reference 3. The following information is attached to this letter:

Attachinent 1 - NRC Identined Weaknesses and Follow-up Items Attachment 2 - Summary of WPSC Event Investigation Attachment 3 - WPSC Response to NRC Identined Items Attachment 4 - Corrective Actions Attachment 5 - Professionalism at the Kewaunee Nuclear Power Plant- "t Attachment 6 - Additional Information on Exercise Control L

As presented at the management meeting, Reference 4,' our assessment of the ~ emergency exercise connrmed some of the items identined by the NRC, but reached a different conclusion on several of the other weaknesses. Although we recognize that our performance declined from prior years' exercises, we concluded that the Emergency Response Organization effectively-managed the event in accordance with the WPSC Emergency Plan. Furthermore, based.on our l

familiarity with the participants in this year's exercise, we are confident that they_ could capably.

handle any event regardless of the degree of complexity _ or level of severity.

Our review did identify two major causal factors for the performance decline this year. These-were scenario weaknesses and, given the large number of personnel in new assignments this year, our failure to adequately convey expectations for player conduct and evaluator / controller -

team performance. The scenario. weaknesses resulted in the need for controller intervention,-

L artificial delays of certain repair activities and the need for the controllers to adlib some of their responses.

The second causal factor, that is the failure to convey performance expectations to the players, evaluators and controllers, contributed to the observed instances of non-professionalism,.the

appearance of lack of command and control in the Technical Support Center, and a less than L adequate self-critique immediately_ following the exercise. Corrective actions have been -

! identiDed to address each of these weaknesses.

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q Document Control Desk December 28,1992 Page 3

-Based on our discussions with the staff, we feel it is appropriate to perform a remedial exercise limited to the Technical Support Center directors, coordinators and. communicators. The objectives of this exercise will be to demonstrate facility activation, prioritization ~of. work activities, delegation of responsibilities, conduct of facility briefings and determination of the need for making potassium iodide available. Performance of this remedial exercise is scheduled .-

for Februany 11, 1993.

If you have any questions or require additionalinformation, please contact Mr. David Seebart at 414 433-1329.

Sincerely, 00( /

C. A. Schrock Manager-Nuclear Engineering SLB/cjt Attach, cc - US NRC - Region III Mr. Patrick Castleman, US NRC ucwacun e n4 m -j l

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Attachment 1 To Letter from C. A. Schrock (WPSC)

To Document Control Desk (USNRC)

Dated December 28,1992 s

NRC Identified Exercise Weaknesses and Follow-Up Items LIO.NROlRVN21 A WP

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Document Control Desk December 28,1992 Attachment 1, Page 1 NRC IDENTIFIED WEAKNESSES AND FOLLOW-UP ITEMS

1. The technical support center was activated before the facility staff was in a cosition to accept command and control of the emergency response. This activation was onsidered untimely. (Section 6.b) (50-305/92021-01)

2. The emergency director and the technical support center staff failed to manage the emergency response. (Section 6.b) (50-305/92021-02)

3. The technical support center staff made an inappropriate evaluation of radiological conditions, contrary to plant procedure, which resulted in the decision to make potassium iodide available. (Section 6.b) (50 305/92021-03) ,

and The lack of instructions given pertaining to potassium iodide use is considered an Inspection Follow-up Item. (Section 6) (50-305/92021-04)

4. The coordination of repair teams between the operational support facility and the radiological analysis facility was inadequate to perform emergency repairs. (Section 6.c)

(50-305/92021-05)

5. The inadeq'tacies in exercise control, including controller prompting, improper controller interaction, and improper simulation, is an Inspection Follow-up Item. (Section 8) (50-305-92021-06)

6. The-licensee failed to adequately critique exercise performance and identify major deficiencies. (Section 9) (50-305/92021-07)

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Attachment 2 To I.etter from C A. Schrock (WPSC)

To Document Control Desk (USNRC)

Dated December 28,1992

SUMMARY

OF WPSC EVENT INVESTIGATION e

LICiNRCilR920'21A.WP

71 Document Control Desk December 28,1992 Attachment 2, Page 1

SUMMARY

OF WPSC EVENT INVESTIGATION Following completion of the annual emergency plan exercise, the NRC identined a number of concerns regarding WPSC's performance. These concerns were provided verbally, immediately  !

following the exercise, and in Inspection Report 50-305/92021. To address these concerns, WPSC management formed a team comprised of three senior employees to conduct an evaluation of the exercise performance. The team conducted their assessment by reviewing the documentation created prior to and during the exercise; by interviewing players, controllers, and evaluators; and then by assembling the information learned in this process.

This assessment confirmed some of the items identified by the NRC, but reached a different conclusion on several of the other weaknesses. Although we recognize that our performance declined from prior years' exercises, we concluded that the Emergency Response Organization effectively managed the event in accordance with the WPSC Emergency Plan. Furthermore, based on our familiarity with the participants in this year's exercise, we are confident that they could capably handle any event regardless of the degree of complexity or level of severity. A summary of our findings in response to those items identified by the NRC is provided below.

The details supporting our conclusions are provided in Attachment 3.

1) The Technical Support Center activation was performed in an acceptable manner. The Emergency Director made an appropriate decision to remain in the Control Room Simulator after relieving the Shift Supervisor, there was adequate staff functioning in support of the event when the center was declared activated, and the activation delay was attributable to an exercise-related equipment problem.

2) The Emergency Director and Technical Support Center staff effectively managed the emergency response and implemented our Emergency Plan, however, there were a few weaknesses, most notably with staff briefings.

3) The Radiological Protection Director accurately assessed the radiological situation and-correctly made Potassium Iodide available to all site personnel, However, there were weaknesses in the manner in which Potassium Iodide was made available to the plant staff. These included insufficient discussion on the basis for Potassium Iodide distribution, insufficient instructions regarding ingestion of Potassium Iodide, and not identifying the locations of Potassium Iodide. There are also some weaknesses in our procedure used for making Potassium Iodide available.

4) A review of documentation and player interviews indicated that there was effective coordination and communication between the Operational Support : Facility and Radiological Analysis Facility with regard to dispatching emergency repair teams.

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l Document Control Desk December 28,1992  :

Attachment 2, page 2

5) There were several examples of weaknesses in the area of exercise control. .

6) The critique performed immediately following the exercise by the players and controllers, and the summary provided the next day were not effective in identifying exercise weaknesses. However, the more detalled evaluation, performed during the weeks after the exercise, was effective in identifying exercise weaknesses.

7) The instances of non professional behavior were confirmed. l Overall, we believe the concerns identified during our review were attributable to scenario weaknesses and, given the large number of personnel in new assignments this year, our failure to adequately convey expectations for player condt.et and evaluator / controller team performance. 1 The scenario weaknesses rcsulted in the need for controller interventiori, artificial delays of  ;

certain repair activities and the need for the controllers to adlib some of their responses.

The second causal factor, that is the failure to adequately convey performance expectations to tne players, evaluators and controllers, contributed to the observed instances of non.

professionalism, the appearance of lack of command and control in Technical Support Center ,

operations and a less than adequate self-critique immediately following the exercise.

From our review we can also understand how the NRC evaluation team may have reached their conclusions. This is based on our findings that the management style of the Emergency Director and Technical Support Center Director, combined with their familiarity and confidence in the support staff, allowed for a consensus decision making process. The NRC inspection team's task of ass:ssing the director's ability to manage was further complicated because the "

"drillsmanship" -- that is verbalization of thoughts and actions, was not as good this year as in the past years.

Corrective actions are in progress for the weaknesses we identified and are discussed in Attachment 4.

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Attachment 3 To Letter from C. A. Schrock (WPSC)

To Document Control Desk (USNRC)

Dated -

December 28,1992 WPSC RESPONSE TO NRC IDENTIFIED WEAKNESSES AND FOLLOW UP ITEMS:

Technical Support Center Activation-Command and Control in the Technical Support Center Potassium Iodide Evaluation Repair Team Coordination Exercise Control Exercise Self Critique 1

UCV4RC\!R9?Mt A.WP -

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Document Control Desk December 28,1992 Attachment 3, Page i

1. TECIINICAL SUPPORT CENTER ACTIVATION The specific weakness as stated in the appendix to the Inspection Report is:

The Technical Support Center was activated before the facility staff was in a position to accept command r.nd control of the emergency response.

This activation was considered untimely. (Section 6.b)

(50-305/92021-01)

The specific items identified in the body of the Inspection Report for this weakness are categorized as:

1. The Emergency Director assumed command and control from the Shift Supervisor at a time that the Technical Support Center staff was not postured to assume responsibility for managinp t's event. Although no major plant evolutions were occurring, the Emergency Dhector remained in the Control Room Simulator for an additional 30 minutes before leaving for the Technical Support Center.

2. At 0910 hours0.0105 days <br />0.253 hours <br />0.0015 weeks <br />3.46255e-4 months <br />, the Technical Support Center Director declared the Technical Support Center activated. This was done before the Emergency Director arrived in the facility and without ensuring that the staff was ready to assume its responsibilities, i

3. The Technical Support Center was activated approximately 45 minutes after the Alert declaration, as opposed to the licensee's 30-minute i activation goal.

Each of these items will be addressed individually. -

11ntL1 The Emergency Director arrived in the Control Room Simulator at approximately 0827, received a briefing from the Shift Supervisor, and relieved him of the Emergency Director duties at 0838 (refer to Figure 1 for a time line). At approximately 0845, the Emergency Director called the-Technical Support Center Director, then located in the Technical Support Center, and informed him that he had assumed the Emergency Director responsibilities and would be functioning from -

the Control Room Simulator to ensure a smooth transition, i

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Document Control Desk December 28,1992 Attachment 3, Page 2 WPSC Emergency procedure EP AD 1, " Plant Emergency Organization," and the Emergency Plan state that the Emergency Director is responsible for the overall direction and supervision of the plant emergency response organization, and that the Technical Support Center is responsible for coordinating support and planning activities. The first instruction to the designated limergency Director in Emergency Procedure, EP-AD-4, " Alert, Site Emergency, or General Emergency," is to relieve the Shift Supervisor. Based on the emergency plan procedures, the Technical Support Center does not manage the event, nor is it required to be in a position to support the event prior to the Emergency Director assuming the director's responsibilities. WPSC expects the Shift Supervisor to be relieved as soon as practical to allow him to focus his attention on plant operations.

When the Emergency Director relieved the Shift Supervisor, he k iew that the Technical Support Center was not ready to function in support of the event. Therefore, he made a conscious decision to remain in the Control Room Simulator where he could manage the event. The Control Room Communicator and Shift Technical Advisor were available to make notincations and assist with classification should the events warrant a reclassification. The discretion to remain in the Control Room is allowed by the emergency plan and implementing procedures.

Appendix A to the Emergency Plan, which lists the duties of the emergency response directors, lists the location of the Emergency Director as " Technical Support Center / Control Room."

Furthermore, we have found through experience with past drills and exercises that this approach ensures a smooth transition of the Emergency Director's responsibilities.

At 0831, the Control Room Communicator started making notiGeations for the Alert. The communicator completed the off site notifications immediately, activated the emergency pagers, and provided status briefmgs to the Technical Support Center. At 0909, the communications for the Alert were complete. The Emergency Director, via the Control Room Communicator, knew that the Technical Support Center Director was near declaring the center activated. Based on the Alert communications being completed and imminent activation of the Technical Support Center, the Emergency Director felt that it was an appropriate time to relocate. This decision was discussed with the Event Operations Director. The Emergency Director left the Control Room Simulator at 0910 and arrived in the Technical Support Center at 0919. (The transition to the Technical Support Center would take only 1 to 2 minutes if the Emergency Director started in the plant Control Room as would be the case in an actual plant event.)

The Emergency Director's actions with regard to relieving the Shift Supervisor of the director duties and his decision to remain in the Control Room Simulator until communications were complete, were in accordance with the emergency plan implement;ng procedures and prudent based on the events in progress and our past experiences, ucm c e w m we l

Document Control Desk December 28,1992 Attachment 3, page 3 1RIIL2 The second item identified by the NRC was that the Technical Support Center Director declared the Technical Support Center activated before the Emergency Director arrived, and it was evident that this facility was not adequately prepared to take over the response to the event.

With regard to the Emergency Director not being present, as was discussed earlier, the Technical Support Center Director knew that the Emergency Director was in the Control Room Simulator. Furthermore, the Technical Support Center Director knew that the Emergency Director's presence was not required to consider the facility activated. The discretion to activate the facility without the Emergency Director's presence is allowed by procedure EP-TSC 2,

" Technical Support Center Activation." The Technical Support Center Director was referring to this procedure throughout the facility activation process.

With regard to the facility not being adequately prepared, the interviews with directors and .

players concluded that adequate staff was available for all the Technical Support Center -

positions. In fact, the staff was already functioning in support of the event before the facility was declared activated. The Technical Support Center Director had conducted one briefing at 0842 and gave a second briefing at 0910 when the facility was declared activated. By the time the center was activated, three maintenance teams had already been dispatched: one to the substation, one to attempt to close the equipment hatch, and one to the B diesel generator.

Communications had been established with the Control Room Simulator and Emergency Operations Facility, and the Engineering Coordinator and Support Activities Director were already researching methods to restore off site power.

What may not have been apparent to the NRC evaluation team was ll.at the Technical Support Center Director was familiar with the staff and their emergency response duties. This familiarity was due to the practice of having predesignated emergency response roles similar to normaljob duties and the drills recently performed in preparation for the exercise.

Based on the responders knowing their predesignated roles, the Technical Support Center Director did not have to formally make position assignments. The NRC evaluation team's task was further complicated by the fact that the Technical Support Center Director was implementing the activation procedure by checking with each of the players individually as to their state of readiness instead of bringing the entire facility into the discussion and the directors were not wearing arm bands as they had in previous exercises. We concluded that this method of facility activation, while not the best to use during an observed or evaluated exercise, is acceptable based on the emergency plan implementing procedures.

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Document Control Desk December 28,1992 Attachment 3, Page 4 IkilL3 The third area noted by the NRC was that the Technical Support Center activated approximately 45 minutes after the Alert declaration, as opposed to the licensee's 30 minute activation goal.

The specine exercise objective stated in the 1992 exercise manual submitted to the NRC was,

Demonstrate the capability of the appropriate Emergency Response Organizations (EROS) to mobilize in a timely manner." The method to c.atisfy this exercise objective as stated in the exercise manual was to activate the Plant Emergency Response Organizations within approximately 30 minutes of the Galtronics notification.

Our review concluded that the Technical Support Center Director was aware of the need to activate the facility in a timely manner; however, there was an exercise related problem with the equipment used to simulate the NRC telephone link. Step 4.1.1 of procedure EP TSC 2 states,

" Ensure communicators have relieved the STA and notifier of communication responsibilities in the Control Room;" therefore, the Technical Support Center Director delayed facility activation until a plan was worked out between the Shift Technical Advisor and Technical Support Center NRC Communicator to resolve this equipment problem. The Technical Support Center Director placed priority on this simulation problem since it was the last item to be resolved prior to declaring the facility activated. We concluded that the activation objective was met and the time delay was acceptable based on the aforementioned communications difficulties.

Summnry for NRC Identified Weakness 50-305/92021-01  !

Based on our review, we have concluded that the Technical Support Center activation _was performed in an acceptable manner. The Emergency Director made an appropriate decision to remain in the Control Room Simulator after relieving the Shift Supervisor, there was adequate staff functioning in support of event when the center was declared activated, and the activation delay was attributable to an exercise-related equipment problem. However, we can understand how the NRC inspection team may have perceived problems with the facility activation in that the "drillsmanship" -- that is verbalization of thoughts and actions, was not as good this year as in past years, u m ca m m we

Document Control Desk December 28,1992 Attachment 3, Page 5 FIGURE 1 IJME LINE FOR TECIINICAL SUPPORT CENTER ACTIVATION 0810 Loss of offsite power and loss of onsite AC power.

0826 Personnel sent to investigate damage in the substation.

0827 The Shift Supervisor (SS) announces the Alert.

0827 The Emergency Director (ED) and the Control Room Communicator arrive in the Control Room Simulator (CRS).

0827 Personnel begin arriving at the Technical Support Center (TSC).

0828 Accountability started in the TSC.

0830 ' First repair team dispatched to close the cor.fainment equipment hatch.

I 0831 Control Room Conununicator starts notifications for the Alert.

0832 NAWAS notification performed.

0838 The ED relieves SS of the ED duties.

0841 TSC Director provides TSC staff with first plant status briefing.

• 0845 ED notifies the TSC Director that he has assumed ED responsibilities.

0902 Accountability completed in the TSC.

l 0908 Maintenance team investigating the IB diesel generator.

0909 Control Room conmmnicator completes Alert notifications.

i 0910 The ED leaves the CRS enroute to TSC.

0910 TSC declared activated - Second plant status briefing.

0919 ED arrives in the TSC.

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Document Control Desk December 28,1992 Attachment 3, Pat'e 6

2. COMMAND AND CONTROL IN TIIE TECilNICAL SUPPOllT CENTEll The specific weakness as stated in the appendix to the Inspection Repon is:

The emergency director and the technical support center staff failed to manage the emergency response. (Section 6.b) (50 305/9202102)

The WPSC Emergency Plan and implementing procedures specify that the Emergency Director is responsible for the overall direction and supervision of the emergency response organization. Appendix A to the Plan states that the primary responsibilities of the Emergency Director are to:

a) Supervise and direct the plant emergency response operations.

b) Approve changes in emergency classification based on plant, equipment and radiological conditions, c) Make protective action recommendations to state and local authorities during the initial phases of an emergency until relieved by the Emergency Response Manager, d) Assure that information relayed to the Emergency Response Manager for release to the news media and the public is technically accurate.

e) Direct the implementation of any corrective actions needed to return the plant to a stable condition, f) Direct the necessary protective actions to safeguard plant personnel.

g) Ensure continuous accident assessment throughout the duration of the emergency, h) Review and approve all exposures in excess of 10 CFR Part 20 limits.

Responsibilities b, c and h may not be delegated. The other responsibilities may be implemented by either the Emergency Director, or by delegation to the appropriate emergency response personnel, t

LINRCIR91Ull A w P

I Document Control Desk December 28,1992 Attachment 3, Page 7 l Our review concluded that these responsibilities were effectively implemented. The Emergency Director and Technical Support Center staff effectively managed the emergency response in accordance with the WPSC Emergency Plan, llowever, from our review we can understand how the NitC evaluation team may have reached their conclusions. This is based on our findings that the management style of the Emergency Director and Technical Support Center Director, combined with their  ;

familiarity and confidence in the support staff, allowed for a consensus decisionmaking process. The NRC inspection team's task of assessing the directors' ability to manage was further complicated because the "drillsmanship" - that is verbalization of thoughts and actions, was not as good this year as in past years, in response to the NRC inspection report we examined the three command and control items identified in the body of the Inspection Report. These are categorized as:

1) " oritization of work activities.

2) The use of engineering resources in the Technical Support Center, o

3) Control of staff briefings.

Each of these items will be addressed individually.

11rBL1 As noted in the analysis of the Technical Support Center activation weakness, the Emergency.

Director was familiar with and had confidence in the emergency response organization staff and their capabilities, The casualty control format provided multiple challenges to the engineering and maintenance organizations including a loss of off site power, on-site diesel generator failures, injured and potentially contaminated personnel, loss of residual heat removal cooling and a large containment opening allowing an unmonitored release path to the environment.

Despite these multiple challenges our review of the event time line, and interviews with players, evaluators and controllers concluded that adequate staff resources were available in the Technical Support Center to cope with all of these situations in a timely and thorough manner.

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1 Document Control Desk i December 28,1992 Attachment 3, Page 8

, I l i in fact, the maintenance and engineering support staffs were more creative and timely in their ,

corrective actions than the scenario team had anticipated. For instance, the Support Activities l Director and Engineering Coordinator devised a method to successfully restore off site power carly in the exercise. Since restoring off site power would have prematurely ended the exercisc ,

the controller team had to adlib a response at 0917 that the substation would be unavailable i throughout the exercise. l Our review concluded that due to the availability of a competent support staff, the Emergency '

Director was not required to verbalize the prioritization of work activities. This may have given the impression that priority decisions did not occurl however, this is not the case. At 0924, the Technical Support Center directors established the cross tic of busses 5 and 6 as the top priority and at 0939, when the attempts to close the cross tie breaker failed, repowering the B residual heat removal pump was established as the top priority. At 1043, the Control Room Simulator requested the A diesel generator fuel oil transfer pump be repaired; the Technical Support Center directors established this as a low priority since there was enough fuel oil available and other maintenance activities took precedence.

Section 6.b of the Inspection Report under the discussion on prioritization of work activities states: ,

At 0929, the event operations director (EOD) in the CRS established the cross tie of buss five to six as the number one priority. The ED received his request and passed it to the operations support facility (OSF) without any discussion of the priority. At 1047 hours0.0121 days <br />0.291 hours <br />0.00173 weeks <br />3.983835e-4 months <br />, the OSF staff directly received direction from the CRS -

to inspect the A residual heat removal (RilR) pump seal. The TSC was bypassed in this request._ While the ED and TSC director were discussing the merits of starting the shield building ventilation system, the CRS staff began the operation.

All of this direction and prioritization was done by the CRS instead of the ED.

in response to this, our review of the event time line, various log entries, and interviews with exercise participants concluded that the three activities described by the NRC were performed  ;

with the concurrence of the Emergency Director, or at his request.

At 0923, an Auxiliary Equipment Operator reported to the Control Room Simulator that steam was coming from the A residual heat removal pump pit (simulated). At 0924, the Control Room Simulator relayed this information to the Technical Support Center directors. The Technical Support Center recorder's log entry for 0924 documents that the bus tie was established as the t

high priority during this conversation. This discussion on priorities is further supported by a UCWROIR9NJi A.WP .,

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Document Control Desk December 28,1992 Attachment 3, Page 9 Technical Support Center evaluator entry made at 0925 stating, "ED and TSCD prioritizing work with S/S setting up entry for RHR. Moved bus 5 up in status ...". These log entries and interviews with the directors involved indicate that the Emergency Director was directly involved in the prioritization of the bus cross-tie.

Concerning work on the A residual heat removal pump, a review of this activity shows that a maintenance team entered the Auxiliary Building at 0940 to inspect the pump seal and started planning the repair job at 1000. (Refer to section 4 on repair team coordination for more detail.) Our interviews with the Technical Support Center Director and Emergency Director concluded that the directors were kept informed of ongoing activities with regard to planned work on this pump and were not bypassed in this activity. WPSC's emergency plan implementing procedures allow the control room staff to directly contact the operational support facility to discuss maintenance activities. It is WPSC's position that this direct interface is beneficial as long as these discussions do not alter established maintenance priorities without involving the Emergency Director. In order to facilitate this direct communication link an individual with operations background is normally assigned to the Operational Support Facility.

With regard to starting the shield building ventilation system, the Technical Support Center recorder's log shows that the Technical Support Center staff was discussing the possible benefits of starting the system at 1122. Immediately following this discussion, the Emergency Director contacted the Events Operations Director and requested that the ventilation system be started.

The Control Room simulator reported back at 1125 that the system was started. That the system was started in response to the Emergency Director's request has been confirmed by interviews with the Emergency Director, Technical Support Center Director, Events Operations Director and an evaluator in the Technical Support Center.

Based on our findings as discussed above, we do not agree with the statement, "All of this direction and prioritization was done by the CRS instead of the ED."

httill With regard to the second item, the use of engineering resources in the Technical Support Center was inadequate, we do not agree with the NRC evaluation team. - The responsibilities of the Engineering Coordinator are described in procedure E-TSC-1 " Technical Support Center Organization". Among these duties is coordinating engineering support activities and providing technical assistance to the Support Activities Director as requested. There was electrical, mechanical, and instrument and control expertise available to support the Engineering Coordinator for this exercise. This support staff is located in the engineering office which is adjacent to Technical Support Center working area. (Refer to Figure 2) In addition, there is the Core Hydraulics Coordinator who is located in upper area of the Technical Support Center and reports directly to the Technical Support Center Director.

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y Document Control Desk December 28,1992 Attachment 3, Page 10 Our h:terviews with the directors in the Technical Support Center, coordinators and their support staffs concluded that the engineering resources were used adequately. They were providing creative corrective actions and were being proactive in responding to the event.

For example at 0810, seventeen minutes prior to the alert declaration when off-site and on site AC power was lost, the maintenance and engineering personnel assembled in the Radiation Protection Office and were proactively formulating methods to close the equipment hatch recognizing this as an area of vulnerability. Throughout the course of the exercise multiple attempts were made to perform equipment hatch repairs and each was stopped by exercise events. The idea to cover the hatch opening with a tarpaulin was generated by the engineering support staff.

As another example, at approximately 0923, it was detected that the operating residual heat removal pump, A, had developed a seal problem, and the B residual heat removal pump was not available due to failure of the B diesel generator. Given that restoring core cooling was the top priority, the engineering and maintenance staffs worked on parallel paths to return a residual heat removal pump to service.

One of the engineers went to the B diesel generator room to provide direction to the maintenance crew in troubleshooting and possible repair activities. In the engineering office the electrical support staff began researching alternate methods to repower the B residual heat removal pump.

The first option, which was to close the cross tie breaker between the A and B train,- did not work due to a simulated breaker failure. Therefore, the engineering staff developed a method i to power the B residual heat removal pump from the Technical Support Center diesel generator. --

The engineering coordinator briefed the Emergency Director and Technical Support Center Director on the idea. After the directors' concurrence, one of the members of the support staff went to the Control Room Simulator to brief the operations staff and direct performance of the activity. Prior to performing all of the steps to repower the B residual heat removal pump, the '

B diesel generator was repaired and energized. Since the B diesel generator is the preferred power supply, the Technical Support Center decided to power the pump from this diesel generator. In addition to these ongoing engineering activities to repower the B pump, maintenance was taking the appropriate steps to repair the seal on the A pump.

Section 6.b of the inspection Report under the discussion on use of engineering resources in the l- Technical Support Center states:

For example, select personnel in the TSC recognized that reactor coolant system -

(RCS) thermocouples indicated a rise in RCS temperature after feed and bleed operations were started. This rise in temperature would have been indicative of l a failure of feed and bleed to effectively remove heat from the reactor,- The TSC

• l staff neither trended nor analyzed the data. This was recognized by the ED and LICWR(NR9202 t A.WP

Document Control Desk December 28,1992 Attachment 3, Page 11 TSC director but dismissed. Once the RllR pump was regained and feed and bleed operations were terminated, the TSC staff claimed that the radioactive release was terminated. Although the driving force responsible for a major portion of the release was terminated, radioactive RCS water was still held in containment, which was still not isolated. The TSC staff did not analyze the release which continued due to the radioactive RCS water in containment, liowever, the TSC staff did develop an excellent idea for powering a charging pump from the TSC diesel generator. Lead TSC staff developed a plan for accomplishing this task.

In response to the statement on feed and bleed operations, the Technical Support Center Director and the Emergency Director recognized that reactor coolant system temperature was rising, but did not dismiss this information. Instead, they knew that in order for the feed and bleed to be effective, the procedure being used by the operators relied on bulk boiling to generate steam thus removing heat from the reactor core. In order for boiling to occur, the reactor coolant system must reach saturated conditions. The core hydraulles coordinator was not formally recording the information, but he was monitoring the core exit thermocouples, reactor coolant pressure and decay heat available on the plant process computer to determine when saturated conditions would be reached during the feed and bleed operation. Additionally, he kept the Technical Support Center Director appraised of core conditions and made a point of notifying him when saturated conditions were reached.

As was discussed with the senior resident inspector following the exercise, there are some shortcomings in the simulator's fide!9y when in shutdown conditions, llowever, the modeling was sufficient to drive the scenario events.

With regard to discussions on the radioactive release, a review of Technical Support Center recorder log entries and interviews with the Emergency Director, Emergency Response Manager and Environmental Protection Director did not confirm the statement in the Inspection Peport that the Emergency Director stated the release was terminated when feed and bleed was terminated. The recorder log entry shows that at 1038 the Emergency Director made a statement that the release should stop shortly, but activities were continuing to obtain reactor coolant samples to determine the amount of fuel failure and iodine component.

In addition, the three directors discussed the status of the release in detail after the B residual heat removal pump was started. Interviews with all three directors indicate that a consensus was reached that additional field samples would be obtained by the monitoring teams and that maintenance would continue their efforts to close the equipment hatch. The Directors did not consider the release terminated at this time during the exercise, ucm ea m m we

I Document Control Desk December 28,1992 Attachment 3, Page 12 The engineering support staff was working on methods to repower the B residual heat removal pump from the Technical Support Center diesel generator, not a charging pump, as is stated in the Inspection Report. Additionally, our interviews with the Engineering Coordinator concluded that the plan was developed by the enginecting support staff and reviewed by lead facility staff.

After the engineering work was completed, the Engineering Coordinator briefed the Technical Support Center and Emergency Directors on the details to obtain their concurrence. The Emergency Director further directed that a member of the engineering staff deliver a written copy of the switching procedure to the control room simulator in order to avoid any possibility of miscommunication.

Based on our review of these activities, combined with the previously discussed example of devising a method to restore off site power, we concluded that the engineering organization was indeed being used very effectively.

liftiL3 With regard to control of staff briefings, we agree with the observations made by the NRC evaluation team. The Emergency Director and Technical Support Center Director provided frequent briefings, but failed to provide detailed information on the plant status and ongoing maintenance and engineering activities. This failure to provide complete status information was due to the fact that the directors relied too heavily on an inter-facility speaker phone system to provide the briefing for the Technical Support Center staff.

This speaker phone system, commonly known as the DAROME, provides an open line of communication between the Control Room Simulator, Technical Support Center and Emergency ,

Operations Facility. In past drills and exercises operation of the DAROME has had minor problems and was used with varying degrees of success. For this exercise the DAROME was turned on at approximately 0900 and performed extremely well allowing frequent communications and timely status updates between the three facilities.

Our interviews with the Technical Support Center players, controllers and evaluators concluded that the adequacy of briefings provided in the facility was dependent on your location (Refer to Figure 2). Those persons seated at the main director's table and just behind the directors felt they were receiving sufficient information by monitoring the DAROME conversations. They were in a position to hear the discussions between the Emergency Director, Technical Support Center Director and other facilities. In their opinion the formal staff briefings contained adequate detail based on their knowledge of the DAROME discussions.

Those players and evaluators in the background commented that they were only receiving one side of the conversation. Generally, they were able to hear the information being provided over the DAROME, but they could not hear what was being said by the Emergency Director or L.lC\NRC\1R92021A WP

I

- Document Control Desk '

December 28,1992 Attachment 3, Page 13  :

Technical Support Center Director. 'Dierefore, they received sufficient plant status information, but were not always aware of decisions being made, or the priorities for ongoing maintenance and engineering activities.

In addition, some of the emergency responders commented that the noise level progressively increased in the Technical Support Center throughout the exercise and the briefimgs made by the directors were not audible throughout the facility. A number of the responders also felt that recent changes in the physical arrangement of the facility were not conducive to group discussions since all of the key players were no longer seated at the same table and the large number of people now physically located in the center may have contributed to the background noise level.

Sittntparv for NRC Ident[{ led Weakness 50-305/92021-02 in summary, we concluded that the Emergency Director and Technical Support Center staff effectively managed the emergency response and implemented our Emergency Plan, however, there were a few weaknesses, most notably with the staff briefings.

1.lC\NRC\lR92021 A.WF

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December 28,1992 171GUltE 2

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Document Control Desk December 28,1992 Attachment 3 Page 15

3. POTASSIUM IODIDE EVALUATION The specific weakness as stated in the appendix to the Inspection Report is:

The Technical Support Center staff made an inappropriate evaluation of radiological conditions, contrary to plant procedure, which resulted in the decision to make potassium iodide available. (Section 6.b) (50-305/9202103)

In addition, an inspection Report follow up item is:

The lack of instructions given pertaining to potassium iodide use is considered an Inspection Follow-up Item. (Section 6) (50-305/92021-04)

The specific items described in the body of the Inspection Report for this weakness and follow-up item are categorized as:

1) The TSC staff made an inappropriate evaluation as to the need for potassium iodide (KI). The TSC made the decision to make K1 available to personnel based on observed radiation levels of 20 R/hr at the containment equipment hatch. The Radiological Protection Director (RPD) determined that a worker could accumulate a 10 Rem whole body dose based on those exposure rates. Procedure EP AD 18, Rev. G stipulates that K1 should be made available when there is a predicted dose of 10 Rem to the thyroid via measured airborne concentrations and projected exposure durations. At the time that the decision was made, the RPD did not have knowledge of the iodine levels in the plant.

2) Additionally, the TSC and OSF are served by a ventilation system comparable to the Control Room. The personnel in these facilities would not have been subjected to this type of iodine exposure and would not have needed Kl.

3) The licensee provided very little information to the staff after KI was announced as available. The TSC directors did not offer any instructions as to its use nor did they identify where it could be obtained. Although the staff is instructed in the use of K1 during general training, the announcement of K1 availability should accompany some brief instructions.

Each of these items will be addressed individually.

LIONRGlR9?JJ! A WP !

Document Control Desk December 28,1992 Attachment 3 Page 16 IWILL in addition to the indications of 20 R/hr at the containment hatch, the Radiological Protection Director also based his decision on the need for potassium iodide on the potential for 50% fuel clad damage and a 10 R/hr indication at the shield building vent system filters. The Radiological Protection Director accurately assessed these indications and determined that a dose of 10 Rem to the thyroid could occur. A review of the scenario package determined that his assessment was correct. However, two weaknesses were identified:

1) The requirement in procedure EP-AD 18, " Availability of Inorganic lodine Salts for Iodide Saturation of the Human Thyroid Gland" to complete a sample analysis prior to making potassium iodide available could result in unnecessary delays.

2) The Radiological Protection Director did not adequately explain to the Emergency Director his reasoning for deviating from procedure EP AD 18 when making potassium iodide available without a sample analysis.

Item 2 Once a potential exists for a dose of 10 Rem or greater to the thyroid, WPSC makes potassium iodide available to all site personnel. The earlier this decision is made, the more effective the potassium iodide. To be of use, potassium iodide should be taken at least one hour prior to -

exposure and is most effective when taken six hours prior to exposure. Included in an employee's decision to take potassium iodide are factors such as location of the hazard, the employee's duties and if these duties could potentially expose him to the hazard at a later time, shift turnover times, environmental controls, etc. The single greatest factor in any employee's decision will be the employee's perception of the risk and benefits of taking potassium iodide.

Since the Radiological Protection Director can not reasonably weigh these factors for each employee, it is up to each individual to weigh the advantages and disadvantages of using potassium iodide and make their own decision.

However, a review of this issue did identify weaknesses in the procedure for making potassium iodide available. Employees know that when potassium iodide is made available there is a potential for a 10 R dose to the thyroid; but, they are not aware of the severity or location of the high dose rates. This limits their ability to make an informed decision.

LICtNRDIR9?c7i A WP

Document Control Desk December 28,1992 Attachment 3. Page 17 lte m 3 In addition to the annual refresher training provided to each employee, every bottle of potassium iodide comes with instructions listing the side effects (Figure 3). However, WPSC agrees with the NRC evaluation team observation that additional information is required when potassium iodide is made available to plant personnel.

Sununary for NRC Identified Weakness 50 305/9202103 and Follow Up Item 50-305/92021-04 in summary, the Radiological Protection Director accurately assessed the radiological situation and correctly made Potassium Iodide available to all site personnel. However, we agree with the NRC that there were weaknesses in the manner in which Potassium lodide was made available to the plant staff. These included insufficient discussion on the basis for Potassium lodide distribution, insufficient instructions regarding ingestion of Potassium lodide, and not identifying the storage locations. There are also some weaknesses in our procedure used for making Potassium Iodide available.

UCNRCiR9N2l A % P

' Document Control Desk FIGURE 3 EPoAD 18 i December 28,1992 PAGE 3 OF 3 Attachment 3, Page 18 REY.G MAY 2 4 m1 i

HOW POT AS$10M IODIDE WORns Patient Putsee insM Fe' Certain forms of sodine help your thyroid gland work right. Most people get the iod:ne they need Itom foods, hke nodued uit or rith. The thyroid can " store" or hold ordy a certain amount af iodine.

THYRO.8L0CK'" , , , ,,43, t3,, ,,,, ,,,,,, , , ,,,, ,,3,, io,1,, ,, , g, , ,,,,,,, 1, the air. This material may be broethed or s*ouowed. It may (POT A&ltved 600 00 entet the thyroid gland and damage it. The damage would prcr loronounced poe TASS +vm tyf oh<sr eds bobly not show itself for years. Cluidten ere most hkely to heve abor p oted % thyroid damage.

f ADLats and sotutioN U S P If you take potassium lodide,it wiu fillup your thyroid gland.

This reduces the chance that harmful radioactive lodine will enter the thyroid gland.

TAKE POTASSIUM IODIDE ONLY WHEN PUBLIC WHO SHOULO NOT T AKE POTASSlUM IODICE SIEALTil OFFICIALS TELL YOU. IN A RADIATION The only smople who should not take potassium ledide are people EMEROENCY. RADIOACT!YE IODINE COULD BE who know they am suergie to lodide. You may take potauluro RELEASED INM THE AIR. POTASSIUM IODIDE (A iodide even if you are taking a edician for a thyroid problem (for FORM OF IODINE) CAN HELP PROTECT YOU. nample, e thyroid heresome or antathyroid drugs. Pregnant and nursing weenen and bebles and chudron may slee take LMs drug.

IF YOU ARE YOLD M TAKE THIS MEDICINE. TAKE IT ONE TIME EVERY 24 HOURS. DO NOT TAKE IT MORE HOW ANO WHEN TO TAKE POTAS84UM IODIDE .

OFTEN. WORE WILL NOT HELP YOU AND MAY IN. Potaseinam lodido should be takes u seen u possible attar CREASE THE RISK OF SIDE EFFECTS. DO NOT TAKE bealsk Mhchain teQ yen. Yeu ekeund take ene den every 34 THIS DRUO IF YOU KNOW YOU ARE ALLEROIC W - Men wW act help you because the thyroid esa "heid' on-IODIDE. (SEE SIDE EFFECTS BEWW.1 ly limitad asseunte of ledine, larger deses wtB lacrosse the riek of e6de of*esta. You we probably be teW aot to take the drug for more thaa 10 ders.

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DIRECTIONS FOR USE a time ye wW be LaMag the dmg.

Use only as dimeted by State or nomi pubuc health authorit;ee la Possible side effecte laetude skin raahes, swelling of b miivary the enat of a redletion emergency. glands, and "ledissa"(estaulc taste, burning mouth and threet.

"" es a head cold, and someumm ADUL AND CHILDREN 1 YEAR OF ,tomach Tablets:

AGE OR OLDER: One til tablet once e A few beve as allergic remet &en with more serious symp day. Crush for smalleMidren. tosaa.'geeuid be fever and joint pains,or awelling of parts of BABIES UNDER 1 YEAR OF AGE: the fees and body and at tinse severe shortases of breath requir. ,

Oaerhalf 11/31 tablet once e day. Crush ing Isassediate medieel ettention.

first, Taklag lodede aney rarely cause ovweetivity of & thyroid Solutboa: ADULTS AND CHILDREN I YEAR OP gland, underectMty of the thyroid glead, or enlargoesent of the AGE OR OLDER: Add 6 drope to one-thyroid gland (gestart half gines ofliquid and drink each day, E: .

BABLES UNDER 1 YEAR OF AG WHAT TO DO IF SIDE EFFECTS OCCUR Add 3 drepe to a smau amount of liquid If the side offects are severe er if you have en allergic twegion.

oneseday. stop uklag potassium Lodida, Then if possible, cau a doctor ce For all desaae format Take for 10 days unless directed otherwim public health authenty for instructions.

by State or local public hemish authortues.

Store at contreued room tempereture between 16' and 30'C($9' HOW SUPPt. LED to 66'FL Keep contalaer ughtly cleoed and protect from light. THYRO BIDCKW TABIE11(Petueiuse ladide. U.S.P.I bot-Do not use the soluuon if it appears broweush in the noule of the ties of 14 tablets INDC 00374472 30] Each wiute round, scored tablet containe 130 mg poteesium iodide.

THYRO BLOCitW SOLUTION IPotassium lodido Solution

• WARNINO U.S.PJ 30 mi t1 it osJ Light resistaat. musured drop dispenug Potassiuni iodide ehould act be wed 6y people allertie to iodide. units INDC 0037 4237 261, Each drop contains Il mg potascum Keep out of the reach of children. In esse of overdose or suergic iodide.

reertion. contact a phys;cian or the pubhc health authority, w ALLAct LA404Afo#utt DESCRieTION Owen of Each THYRO,BLOCKW TABLET contains 130 mg of CAnttA W AttAct. INC.

potassium iodide.

Each drop of THYRO BLOCK" SOLUTION contains 21 mg r,f issuet@79 CW- 1079 t $- t019 pot sssium lodide.

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Document Control Desk December 28,1992 '

Attachment 3, Page 19

4. OPEllATIONAL SUWORT FACILITY / RADIOLOGICAL ANALYSIS FACILITY COORDINATION  ;

The specific weakness as stated in the appendix to the Inspection Report is:

The coordination of repair teams between the Operational Support Facility and the Radiological Analysis Facility was inadequate to perform emergency repairs.

(Section 6.c) (50 305/920214)S)

Prior to determining the specifics associated with the two examples of poor communication and coordination cited by the NRC inspectors, our assessment of this ,

issue addressed the following:

1) What is standard practice for the interfate between Maintenance and Health Physics personnel during normal plant operations and during an exercise?

AND

2) What was the general impression among the players, controllers, and evaluators of the communication and coordination between the Operational Support Facility and Radiological Analysis Facility?

In brief, the interface occurs as follows during normal plant operations:

a) A work request is generated.

b) A maintenance supervisor will assign the work request to an individual or a group of workers.

c) _ One or more of the group members will discuss the work request with l{calth Physics personnel to determine if an existing radiation work permit can be used or if a new radiation work permit must be written.

d) The required tools, procedures, drawings, spare parts, etc.. are obtained either in parallel or following discussion with licalth Physics; this depends on urgency and available resources.

c) After shift supervisor approval to start, work commences.

During an emergency or an exercise, paperwork for the work request and radiation work permit are allowed to lag behind the maintenance personnel if conditions require l immediate action. This is allowed by procedures EP AD-ll, " Emergency Radiation Controls" and EP-OSF-03, " Work Request During an Emergency."

LICNRC,1R9102 t A YP i

Document Control Desk December 28,1992 t

Attachment 3, Page 20 For a repair requiring a controlled area entry during exercise or emergency conditions, the maintenance personnel will proceed to the Radiation Pro:ection Ofnce or Radiological Analysis Facility and enter the controlled area under the escort of a h:alth physics technician, if required. The repair team then reviews the situation and determines what i actions are required, if special tools, spare parts, or support from other organizations are required, the team may have to exit the controlled area and coordinate these activities. This face to face communication between Maintenance and Health Physics personnel along with the hands on health physics involvement ensure good coordination.

Our assessment showed that communication between the Maintenance and the Health Physics personnel was good. However, it appears as if the status of the repair teams was not reviewed during Technical Support Center briefings. This made it difficult for personnel not involved in the repair activity to know the status of the work in progress.

To assess effectiveness of the repair activities, the two examples described by the NRC were put on a time line to see if communication or coordination problems resulted in unnecessary delays.

1 A RHR Pumo Seal Reedt Concerning the repair activities associated with the A RHR pump seal, the inspection report stated:

At 1050 hours0.0122 days <br />0.292 hours <br />0.00174 weeks <br />3.99525e-4 months <br />, the OSF director received indications that radiation levels at the equipment hatch had decreased sufficiently such that maintenance could be performed on the A RHR pump seal. The team, which had been in " HOLD" status since the start of the radioactive release, was reassembled and sent to the RAF access point. The team arrived at the RAF without any briefing by 1100 hours0.0127 days <br />0.306 hours <br />0.00182 weeks <br />4.1855e-4 months <br />. The RAF staff had no knowledge of this team's task RAF personnel t questioned the team on exposure extensions, number of shif:s to be used, and exact work task. All of this information was not readily attainable from the team. .

RAF per;onnel informed the team that a radiological assessment would have to be done to evaluate the dose rate in the immediate area of the pump and to evaluate the need for respiratory protection. These activities could have been completed prior to the team's entrance at the RAF. This team was indefinitely detained through the end of the exercise at 1200 nours.

The attached time line provides an assessment of this activity. In summary, it shows that the team was not on hold since the start of the radioactive telease, and the team

, coordinated with the Radiological Analysis Facility to develop a radiation work permit for the repair early in the repair process.

UCNRCdR92071 A.WP

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0827 0923 0930 0940 0956 MAO NOTIFIES NCO A RER FUMP 1 MECHANIC AND 1 HF AIIRT DECLARED ^

EDSSOF ALL AC THAT STEAM IS COMD$G 11tIFS. AllRER TECE. ENTER AUI. BLDG.TO FOWER FOR IISS THAN FROM TEE A RER FUMP EOST. (1.3) MTST] GATE STEAM COMthG 15 MLNUTES. (B) FIT. G.3). FROM A REWL FUMP FtT.

MarisaNIC SUsFECTS SEALFAEILME. Q.4)

NOTES ACRONYMS

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2. Ama.aus. Access tos 2. Dc: sement w 3.Ce= ares R - 1 e' 3. nF: sembhrayaks 4.1.e r.n s W uh h med (m%

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" .o*on A RIIR PUMP SEAL REPAIR -a - E ao 8u e.

M o N

1035 1047 1020 1000 5 RHR EW RFD REQLTJTS A NEW MECilAh1C EXITS REFAIR TEAM CONTACTS OSF "M NDU DOSE RATE f1 TOM RAF FUR AUX BIDG. Q) OPERATIONS FERSONM-THEY TO MM RHR FUMF FIT ARIA. Op i WIIIH ANG TAGS AND BEGIN N N"U l DRAINING SYFIDE. D) WAS RESTORED TO THE FUMP C).

MECH ANIC BRIEFS OSF COORDINATOR-THE JOB IS Gnu A IDW FRIORITY. PAST EXPERIENCE HAS SHOWN THAT IT TAEES AFFROXBiATELY 16 HOURS TO REPAIR THE FAST EXPERIENCE SEAL IN ADDITION TO THE 4 TO 6 HOURSTO HAS SHOWN THATIT DRAIN THE SYSIEM. M)

TAs:ES 44 HOLMS TO DRAIN THE RHR FUMP FOR A SEAL i a

' REPAIR M)

HIGHER FRIORITY IS GIVEN TO:

1.REFAIRING THE 13 DG 2.1HE CROSS TIE BETWEIN BUS 5 AND 6

3. POWERING B RHR PUMP FROM THETSC DG. M) 2 0111ER MECH ANICS ASSIGNED TO THE Jos.

ETRST MECHANIC BRIEFS THE TWO MECH Ah1CS. M)

(

l TEAM BEGINS TO SET UP FOR JOB.

1.ONE MECHANIC SITS DOWN WITH HP TO DISCUSS JOB AND WRITE RMT, GMTFILE5'.TJW5 FLO RWF92-DR111.

2.OTHER MEMBERS ASSEME1E DRML PROCEDURES, ARRAhGE FOR WR, %R IS2M2. M)

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Document Control Desk December 28,1992 Attachment 3, Page 24 Containment Eculpment Hatch Closute The NRC stated the following concerning the attempts to close the contamment equipment hatch:

The team assigned to close the containment hatch arrived at the RAF at i150 hours. Even though this team had been on hold since the release had begun, the team was still discussing the method of closing the hatch when they arrived at the RAF. It was also noted that the team had not obtained any equipment for the work to be done. This team was dispatched into the plant at the conclusion of the exercise.

The attached time line provides an assessment of this activity. In summary, it shows that two teams made repeated attempts to close the equipment hatch. When necessary, they coordinated with the Radiological Analysis Facility. During these repeated attempts, one team was delayed due to controller intervention.

TIC.NRC41R97021 A WP

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,', " e CONTAINMENT EQUIPMENT IIATCII CLOSURE u a rc 0827 0830 0810 +

t ALERT DECLARED, my AG.

tOSseu. AC rowu Stoc.TO CinSE ,

ALL AC HATCII. (1) 1 if0R LESS T'IAN 15 N

MINUTES. (4)

SEVERAL ATTEMF13 MADE AFTER DISCUSSIONS BITTI TO C1DSE II ATCH - ALL ENGINEERING. A DFLISION FAIL SO SCENARIO wAS MADE10 llANG TART OVER CAN CONTINUE. CI OPENTNG. SECOND CREW ON OUTSIDE OF CSM NEIDED TO ASSIST IN llANGING TARF. G)

MAINTENANCE SLTERVISOR DISPATCIIES A TEAM OF MECHANICS TO CLOSE A THE EQLTMENT 11ATCH C)

2. REFAIR CHAIN FULL

3. CthSURE BY HAM)

4. COME-A-lhNG G)

Amwivms g,

1. Aam. BWg. Access legs

1. Ass. Sk!g.: Ammibary hg

2. Innerviews with Mechasucs, IIP, and evaluaten 2.CNTMT: Car e Am s

(as tisses appresisustel 3.DC: Dwed Ger_arator 4.Itri Henkh Phyncs 3.13C les

• Support Faabey 4.RAFIag 5. OSF: O m .

S.Netes frees T5C Raessag Serntary 6. FRT: F.-_ h RdwfT M

7. Q A: QumEey Assuramre

6. Neses frees QA Eveleaner

3. RAF: Radselegical Analysms Funsfy

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9. Notes frees llP centraner G \WITILLstTlWI I LO 1 - - _

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CONTAINMENT EQUIPMENT IIATCII CLOSURE /g~[O M o a .

09.;S "

0910 0935 0915 .

i SECOND MAINT. TEAM CNTMT EVACUATED SECOND TEAM H) RADIATION ARRIVES AT THE DUE TO A EDSS OF RE1X LSED WTTH REFORTED IN RAF TO INVESTIGATE ALL RHR HP C"WERAGE Q) CNTMT. 2nd TEAM FOSSSI1JTY OF HANGING SIhT BACK TO OSF Q,4)

TARP-NO HP CO)TRAGE NEEDED AT THIS TIME Q)

SECOND TEAM CONTACTED AND FUT ON HOID TEAM BEGINSTO ASSEMBIZ

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EXERCISE ENDS

DOSE AT HATCH . RFD REQUESTS AN

,_ AIR SAMF1R FROM memm l SONet MR/HR M,7) ARRIVES AT RAF- WILL -

BATCH AREA.(P) A!BST ECOND TEAM FOM INEDE EBEEEED RUHDENG. (1)

' RFD GAVE SAD' FERMISSION TO WORE -

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CONTROUERINDUCES A delay OF 19 MINUIES ENCE EIERCrE A1AGOST OVER.9)

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Document Control Desk December 28,1992 Attachment 3, Page 28 Summary for NRC Identified Weakness 50-305/92021-05 In summary, there was good coordination of the repair teams between the Operational Support Facility and the Radiological Analysis Facility to perform emergency repairs.

The repair team for the A RHR pump continuously pursued repair of the pump seal. The team contacted Health Physics early in the repair process and worked with them to develop a radiation work permit. In addition, they coordinate > rub operations to drain the system, obtained the required procedures and initiated t'- m casary paperwork to obtain the required spare parts. ,

The attempted repairs for the containment equipment hatch were coordinated by two repair teams that made repeated attempts to close the containment hatch throughout the exercise. The teams worked closely with Health Physics and obtained all necessary coverage. Towards the end of the exercise, a team was delayed; however, the controller admitted artificially delaying them since he knew the exercise was almost completed.

UC%NRCIR9202t A w?

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Document Control Desk -

December 28,1992 -

Attachment 3, Page 29

5. EXERCISE CONTROL The follow up item as stated in the Inspection R prt is:

The inadequacies in exercise control, including controller prompting, improper controller interaction and improper simulation, is an Inspection Follow-up item.

(Section 8) (50-305/92021-06)

An important aspect to this item that was identified in the text of the Inspection Report is:

The scenario provided controllers with challenges which they were unprepared to meet.

The specific items identitied in the body of the Inspection Report for this follow-up item are categorized as:

1. Controller prompting and improper interaction.

2. Improper simulation.

3. Scenario package deficiencies.

Each of these items will be addressed individually.

0 Ite m 1 Isolated instances of controllers providing unearned data and improper interaction did occur as discussed in the ' Inspection Report. The controllers involved were interviewed and acknowledged that their actions were incorrect. Details of these interviews are available in -

Attachment 6.

Item.2 The two examples of improper simulation discussed in the Inspection Report did occur. One l concerned dosimeter distribution and the other al.ti-contamination clothing.

He simulation of dosimeter distribution to emergency response personnel was improper. This-simulation did not allow the radiation. protection group to determine if the inventory 'of emergency dosimeters is adequate to provide coverage for the emergency response staff, or if-the dosimeters could be distributed in an effective and efficient manner.

LICWRCi1R92021A.WP

Document Control Desk December 28,1992 Attachment 3, Page 30 The simulation of donning and wearing anti-contamination clothing was allowed by a controller despite a pre stated exercise objective to not simulate this activity. This simulation occurred during the early stages of the event, when a simulated containment entry was made to close the containment equipment hatch.

It is important to note, however, that not all response tasks required full anti-contamination clothing. In some cases decisions were made, based on the simulated radiological conditions ~

known to the players at the time, to send teams into the controlled areas of the plant in lab coats, gloves, and shoe covers. For example, the team entries to obtain an air sample near the residual heat removal pump pit and to obtain a reactor coolant system sample did not require full protective clothing or respiratory devices, Item 3 ,

We agree with this NRC observation; our own event assessment identified areas where the scenario package content hampered the controllers ability to control the event and the players' ability to demonstrate their skills.

The scenario this year was designed to provide a different set of initial conditions to the' Emergency Response Organization. The unique set of challenges included an event starting 3 during cold shutdown conditions with the steam generators unavailable for cooling _and a large containment opening, The story line was sound, however, some mini-scenarios were not fully developed.

For example, the loss of off-site power mini-scenario should have provided realistic system damage which would have required continuous player effort and attenti:,n throughout the exercise. A lack of detail affected the ability to adequately control the event. This resulted in the players abandoning their efforts early in the exercise.

Another example was the containment hatch closure mini-scenario. In this case, controllers were able to improvise and inject obstacles into the players success path. However, this type of control frustrates the players and discourages aggressive player response.

Our assessment concluded that management expectations were not adequately conveyed to the -

scenario team, including the need to place a high priority on the manhour commitment for scenario development. Also, the selection of scenario team members should have been more carefully considered, taking into account normal work load and availability of some scenario team members.

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Document Control Desk December 28,1992 Attachn r,nt 3, Page 31 Summary for NRC Identified Follow-un Item 50-305/92021-06)

In summary, we recognize the need for improvement in the area of controller training to eliminate prompting and improper interaction, and to consistently control to the desired level of simulation. We also recognize the need to place a higher priority on scenario development.

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1 Document Control Desk '  :

December 28,1992- ,

i Attachment 3, Page 32

. 6. EXERCISE SELF-CRITIQUE The specific. weakness as stated in the appendix of the Inspection Report is:

The licensee failed to adequately critique exercise performance and identify major '

deficiencies. (Section 9) (50-305/92021-07) .

This exercise weakness is focused on two areas. They are: i In the TSC, the controllers and evaluators failed to provide any criticism of the exercise to the participants.

AND- ,

... the licensee _ provided .a summary .of its preliminary, self-identified ' performance strengths and weaknesses, which were not in agreement with the inspectors' preliminary.-

- findings.

These two NRC observations are best addressed together and preceded by an explanation of-the -

- WPSC two phase review process. The first phase consists of self-critiquesfimmediately) following the exercise and the second phase is a follow-up evaluation report issued subsequent to the exercise.

The combined effort of three groups is depended upon to perform this total review process. _

These are the Quality Assurance (QA) department, the Nuclear Technical-Review group, and the players and controllers as-a group. Taken together, they provide a. complete view of -

WPSC's ability to respond to emergencies.

Emergency Plan Maintenance Proeddure, i!PMP-2.4, " Drill and Exercise Critiques" was _ written -

in June 1992, to define the self-critiqae phase. As specified by the procedure, the self-critique,

~

phase should be performed promptly following the exercise by the players and controllers. This-phase consists of three steps:

a) in facility critiques lead by the facility directors in order to obtain player input with active participation by the controller, b) a controller critique following the in-facility critiques in which controllers review the player comments _ against their'own . observations to look for common or -

inter-facility areas of concern, and LICWRC\!R92021A WP - ,

c .

Document Control Desk December 28,1992 -

Attachment 3, Page 33 c) a company critique conducted to summarize the identified areas of concern and identify sources ofinformation that would lead to root cause determination of real problems.

The QA department and the technical review group perform the evaluation phase. Their focus is to provide an independent review of programmatic and performance aspects of the cmergency preparedness program. Their evaluations include a review of emergency responder training, the scenario's ability to drive exercise objectives, the players and controllers performance during the exercise and the ability of the players and controllers to perform a self-critique. Therefore,-

the evaluators do not participate in the immediate self-critique process.

After a complete review of all their findings, the QA department and technical review group write their evaluation report. This constitutes the follow-up evaluation phase of WPSC's review process.

Our assessment of the exercise review process identified that there was a misunderstanding between the Emergency Preparedness group and QA department on how this evaluation phase would integrate into the exercise review process this year. In late 1991 the evaluation activities were placed under the coordination of the QA department. This was done to enhance the independence of the review conducted in accordance with 10 CFR 50.54 (t).

For prior exercises, the evaluation wu performed, in part, by contracted support. These contractors also provided significant input to the exercise self-critique phase. Because of this year's change, the evaluators did not participate in the self-critique.

The Emergency Preparedness group misunderstood the role of the QA department in the player and controller self-critique phase. It was believed that the evaluation team would actively participate in the post-exercise critique process. When in fact, the team was evaluating the self-critique phase and did not intend to present their findings until a thorough assessment of their observations had been completed. Based on this misunderstanding, procedure EPMP-2,4, " Drill and Exercise Critiques," when _ written, did not adequately define the critique process as intended.

In addition, the expectations from the self-critique phase were not adequately explained to the controller team. Specifically in the area of their involvement in the in facility and controller critiques following the exercise. This happened because of the way procedure EPMP-2.4 was written and an emphasis placed this year on bottom line performance focusing on protecting the public and bringing the plant to a safe condition. This emphasis limited the control team input during the controller critique, therefore, some of the more specific concems were not identified during the company critique. This misunderstanding of the evaluation phase and the direction and emphasis given to the controllers led to a reduced level of immediate self-criticism.

LICNRCMR92021 A.WP

Document Control Desk December 28,1992 Attachment 3, Page 34 The weakness in the critique process this year does not mean that significant issues were not identified. The combined effort of the QA department and the Nuclear Technical Review group did identify significant concerns similar to those observed by the NRC evaluation team such as attention to briefings, potassium iodide availability, and the critique process.

The evaluators also identified issues in addition to those identified by the NRC evaluation team, such as: promptness of training on revised Emergency Plan Implementing Procedures, and _

coordination of environmental sample counting.

Also, the players and controllers provided significant written comments and observations, such as: the work location of response personnel in the Technical Support Center, QC coverage for repair tasks, and the role of operations in the Operational Support Facility.

Summnry for NRC Identified Weakness 50-305/92021-07 In summary, the self-critique phase immediately following the exercise was weak this year when compared to previous years exercises. This weakness was due to the Emergency Preparedness group not fully understanding how the QA department would fit into the exercise review process, and direction provided to the controllers during their critique. However, we do have the ability to perform an adequate exercise critique when the two review phases, that is the player and controller self-critique, are brought together with the QA department and technical review group's evaluation.

LICiNRCMR97021 A WP

,4 .

Attachment 4 To Letter from C. A. Schrock (WPSC)

To-Document Control Desk (USNRC)

Dated December 28,- 1992 Summary of WPSC Event Investigation and Corrective Actions LIONRC\IR92021 A WP

b Document Control Desk December 28,1992 Attachment 4 Page 1 CORRECTIVE ACTIONS This section discusses corrective actions that have been or will be taken to address the weaknesses identified by our review of the emergency plan exercise.

1. Management involvement Due to some decline from previous years' performance during the 1992 evaluated exercise, more management involvement will be provided to the Emergency Preparedness program. Senior Nuclear Management personnel will increase their level of participation in Emergency Preparedness activities. In particular, the Manager Nuclear Plant Support Services has been designated as responsible for the nuclear portion of scenario development and exercise performance. He will be involved with early planning meetings, scenario development meetings, controller training, player briefings and critiques. He will also monitor the progress of training. His primary role will be to assure adequate nuclear resources are being provided to the Emergency Preparedness program and to assess performance of nuclear personnel in Emergency Preparedness activities. He will also convey expectations of Senior Nuclear Management to the nuclear participants. The Director Governmental Affairs and Emergency Preparedness will be more involved in selecting Emergency Response Organization personnel, attendance at scenario meetings and controller training with the primary purpose of further emphasizing the expectations and requirements of the emergency preparedness program to meet regulatory objectives, both on site and off site.

Status: Complete. The Manager - Nuclear Plant Support Services has been designated to implement this ongoing responsibility.

2. Established Scenario / Control Team Long term assignments for the scenario / controller team will be made. The duties and responsibilities of these team members will be assigned as major responsibilities. Personnel will be selected for the team based on their skills, knowledge, position, and previous performance. We anticipate that some rotation will occur to enhance the knowledge ofindividuals. The main emphasis will be, however, to have in place a core group of people who are knowledgeable not only in their areas of expertise, but who will understand what a good exercise needs in terms of scenario, time lines, data packages, and exercise control.

Status: Will be completed by March 31,1993.

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Document Control Desk December 28,1992 Attachment 4, Page 2

3. Trainine Specific training in areas which will enhance director's ability to demonstrate leadership skills will be provided. A course has been provided to people involved in hazardous material control. It is essentially incident commander training to demonstrate leadership skills in crisis situations. Appropriate portions of this training will be adapted and incorporated into proficiency training for directors.

Directors will also receive training on proper format for conduct of periodic briefings. Subjects willinclude frequency, format, and assurance of participation by key personnel. In conjunction with this, players will receive as part of their Emergency Preparedness training, information on the importance of director briefings and a proper protocol to be used when briefings are being held.

Specific prioritization of activities (i.e., communicate critical information or listen to the briefing) will be discussed to ensure a better understanding by all involved.

The importance of verbalizing thoughts and actions will be re-emphasized to Emergency Response Organization personnel. Key decisions, important communications, and select activities must be effectively demonstrated. This will be included in player briefings for future drills and exercises.

Status: Will be completed by October 31,1993.

4. Esdttin While we normally welcome observers from both in and outside the Company at ,

exercises, we will address the concern of too many non-players in facilities which could hamper effective communications. We will also look at facility layouts to see if improvements can be made to allow better communications and reduce distractions.

Status: Will be completed by September 30,1993.

5. Potassium Iodide (KD The procedure for potassium iodide will be revised to allow knowledgeable .

directors to promptly make available potassium iodide based on current or anticipated plant conditions.

4 LICWRCim?2021A W7

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Document Control Desk December 28, .1992 Attachment 4, Page 3 The process of making potassium iodide available will be revised to provide more detail on its location along with instructions to assure personnel are aware not only of the plant conditions and potential radiation doses, but the potential' for-side effects of using potassium iodide as well. The information will be provided prior to making the dnig available.

Status: Will be completed by March 31,1993.

6. Critiaue Process As pointed out earlier, several contributing factors led to a less than adequate immediate self cr..ique of concerns for the 1992 exercise. Several steps will be taken to enhance this process:

First, the emergency plan will be revised to better define the relationship between the self-critique process and the evaluation process.

Second, procedure EPMP 2,4, " Drill and Exercise Critiques", will be revised to provide specific direction on conduct of post drill / exercise facility player critiques, controller critiques, and company critiques. We also will identify, at '

the company critiques, areas which might be of concern but require follow-up.

Third, during company critiques, we will return to the format of a facility by facility review along with defining interface points either as strengths or possible areas for improvement.

Fourth, management personnel will be more actively involved in the presentation of critique results during the company critique to emphasize the importance of the critique process.

Status: The emergency plan and procedure revisions will be completed by -

August 31,1993. Management involvement'in the critique process will be an on-going commitment.

LIONRCIR92021 A.WP

Attachment 5 To Letter from C. A. Schrock (WPSC)

To Document Control Desk (USNRC)

Dated December 28,1992 Professionalism at the Kewaunee Nuclear Power Plant Presentation Made by the Plant Manager at the December 2,1992 WPSC-NRC Management Meeting L

LICNRCIR92021A WP

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Document Control Desk December 28,1992 1 Attachment 5, Page 1 i PROFESSIONALISM AT KNPP Needless to say, when we were briefed by the NRC on the conduct and behavior observed in the Technical Support Center staging area and other locatio'is, we were not pleased. The i j

behavior described certainly does not meet management expectations, l

On the Friday following the exercise, a meeting of all the players, evaluators and controllers i frem the Technica; Support Center, Operations Support Facility and Radiological Analysis-Facility was called by the Plant Manager. The purpose was to discuss activities and behavior in the Technical Support Center. The players involved openly admitted to the examples brought out by the NRC observers. When questioned why some of these activities were going on, they _

mentioned that they felt it was permitted and cited past examples where card playing and-magazine reading was allowed in the general assembly areas (i.e., the lunchrooms) during exercises and drills. When the assembly / accountability area was changed for some of _the staff to the Technical Support Center / Operational Support Facility staging area, they continued this practice. When questioned if they thought this behavior was acceptable, they agreed, in hindsight, that it was not appropriate.

After searching into the possible reasons why some of the lack of professionalism occurred, or more importantly why it surfaced during the exercise, we came to the following conclusions.

Management had, over time, allowed a certain amount of minor inappropriate behavior to occur. '

Through a combination 'of naivety and unwillingness to correct individuals, it had precipitated to the unacceptable level observed in this exercise. - In addition, we had created an atmosphere which was conducive to this type of behavior. We put quite a few people in a room with no out:ide communication or information to keep them alert or in tune with the activities associated--

with the exercise. We expected them to just sit there and do nothing while waiting for a call to support a field activity. -

To correct this situation we are looking at two actions. First, we will try, through some

" hardware fixes and possibly establishing a staging area coordinator, to create an atmosphere where the people waiting in the staging areas are kept informed and involved._ Second, each of the nuclear managers are meeting with their work groups to discuss professionalism, appropriate -

behavior during exercises and other plant activities, and are letting these individuals know with-no uncertainty what management expectations are, and what is considered acceptable behavior.

LIC\NRCV"97021 A.wP i

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Document Control Desk December 28,1992 Attachment 5, Page 2 l

l Before I leave this area, I want to balance the scales a little bit. We can't leave here giving you  !

the impression that we do not have professional, qualified, knowledgeable and dedicated people.

In fact, my experience during plant events such as the two recent reactor trips is quite opposite from the exercise observations. During these two events the support from all plant staff and support organizations was tremendous. Our dedication to ensuring the plant was in a controlled and stable condition, our pursuit of the root causes and analyzing all the anomalies uncovered, and our resolve to correct all these problems and document their safety significance was the best I have ever experienced. In addition, my observations of work during less stressful and more normal conditions is that all work activities are carried out in a very professional, diligent manner. My personal observations of operator field activities, maintenance repair activities, and other routine duties of plant personnel proves to me that we have a very knowledgeable, dedicated and professional staff. These observations are supported by plant indicators and were recently supported by an INPO Evaluation and Assistance Team. Maintenance backlog and rework is small, operator errors are also minimal, work communications between groups is good as evidenced by lack of interface problems, and finally, our overidl performance indicators are evidence to support this claim.

Overall then, we have concluded that the behavior observed duting the exercise is not pervasive.

We do feel we need to better communicate management espectations and help avoid future situations by creating an atmosphere more conducive to activr; participation versus sitting around.

LICNRCMRt2028A WP

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'l Attachment 6

.To Letter from C. A. Schrock (WPSC)

To Document Control Desk (USNRC)

Dated December 28,1992 Additional Information on Exercise Control 1.!CNROIR92021A.WP -

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l Document Control Desk December 28,1992 Attachment 6, Page 1 Exercise Scenario and Control Controller Prompting and Improper Interaction

1. "At the time of the Alert declaration, the SS asked the controller for the meteorological data. Instead of providing information for the specific time, the controller provided the player with the data for the entire exercise."

The

a. An interview with the controller involved con 5rms this observation.

controller indicated that it was his intention to only allow the player to take the one data point needed and not keep the full page for the entire drill. However, the controller admitted that it was not the proper thing to do because the player, at a glance, could get insight into the future events influenced by weather conditions.

2. "At 0933 hours0.0108 days <br />0.259 hours <br />0.00154 weeks <br />3.550065e-4 months <br /> in the TSC, a controller was observed briefing a player on the known status of Iglured persons. The controller provided the information instead of allowing the player to obtain it through his own re curces."

We agree with this NRC observation. The following clarification and additional information was obtained through controller and player interviews.

a. A player was attempting to obtain information concerning the status of the victims that had been sent to the hospital. The player contacted the Radiological Protection Director but the director did not have any information. The player then went to a controller and was directed to contact the control cell for off-site agencies.

Instead of directing the player to the control cell the controlle should have asked the player the question, "Where would you go to find this information if it were a real event?" If the player said the hospital the controller should then provide the control cell number.

b. When called, the control cell informed the player that the victims were at the hospital but their status could not be given out until families had been notified.

c. A controller recalled that the player and the controller did recap the known status of the victims while at the plant but the controller did not give the player information on the condition of the victim at the hospital. The Controller realizes that he should not have revealed the known information with the player but instead asked the player where, on-site, he should go to obtain that known data.

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Document Control Desk l December 28,1992  ;

Attachment 6, Page 2 l

d. The interviews also revealed that the scenario package did not provide the control cell with the appropriate follow-up information needed for simulated victims after they arrived at the hospital.

3. "The licensee simulated sampling of the RCS to determine the amount of possible fuel damage. The controller provided the results within an unrealistic time frame of ten minutes from the sample time."

a. A discussion with the KNPP Chemistry Group revealed that the time required to obtain and count a diluted RCS sample was approximately 25 minutes. This represents 15 minutes to draw the sample and 10 minutes to count the sample,

b. The controller providing this information was interviewed and agreed with the NRC observation that the sample results were provided after only 10 minutes.

The controller admits to losing track of the time and that 25 minutes would have been a more realistic time frame.

4. "

... the TSC controller presented the player with the reactor coolant isotopic data for the entire scenario instead of for a single point in time."

a. We agree with this NRC observation. In an interview with the controller, the controller recognizes that this was an improper action that provided unearned data to the players.

5. " Prior to the conclusion of the exercise, the players in the OSF were discussing proper OSF functions and interfaces. A controller in the facility also added to the discussion."

a. We agree with this NRC observation. In an interview with the lead Operational Support Facility controller, the controller indicated that a conversation of this nature was held near the end of the exercise. In the controllers' opinion at the time of the discussion, the discussions did not influence the play of the emergency response organization and that they were taking advantage of an opportunity to discuss response improvements for the future. The conversation centered around the most effective use of operations personnel in the Operational Support Facility to process emergency work requests.

LIC\NRCMR92@ A.WP