ML20132D182
| ML20132D182 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 06/10/1985 |
| From: | Dircks W NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO) |
| To: | |
| Shared Package | |
| ML20132D185 | List: |
| References | |
| TASK-PINV, TASK-SE SECY-85-208, NUDOCS 8507090487 | |
| Download: ML20132D182 (8) | |
Text
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wm l p aarco June 10, 1985 SECY-85-208 (Notation Vote)
For: The Comissioners From: William J. Dircks Executive Director for Operations
Subject:
INCIDENT INVESTIGATION PROGRAM
Purpose:
To request the Commission's approval of the staff's plans to improve the existing program for the investigation of significant operational events.
Background:
A recent study by the Brookhaven National Laboratory (BNL) identified a number of ways in which the NRC program for the investigation of significant operational events could be improved. The staff has reviewed this report as well as additional coments on this subject that have been prepared by ACRS and OPE. In addition, the staff has considered the comments provided at the Comission meeting on this subject which was held on May 9, 1985.
s Discussion: As a. result of this evaluation, the staff has identified a numbef of changes in the existing program for the investigation of significant incidents that will substantially improve the program and will incorporate the substance of the comments and recommendations that have been made by the various groups that have reviewed this issue. The general concept and character-istics of these changes are given below. The specific details of the changes will be developed during the coming months as
, the detailed procedures for implementing this program are I
developed.
The Incident Investigation Program In order to ensure that the investigation of significant events is structured, coordinated and formally administered, the staff plans to develop and implement an expanded program of event investigation. This expanded and strengthened program contains two new initiatives. For the few significant events with clear and serious implications for public health and safety, an inter-office, interdisciplinary team will be formed to conduct a CONTACT:
Frederick J. Hebdon, AE00 492-4480 _,__
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The Commissioners prompt, thorough and systematic investigation of the event. l For a larger number of events with lesser significance or whose implications are not as clear, the regional-based investigation will be augmented by the assignment of one or more headquarters technical expert (s) who will participate directly and fully in the event investigation and analysis, and preparation of the final report.
The general concept and characteristics of the revised incident investigation program are discussed below. ,
- 1. Significant operational events (reactor and nonreactor) will be investigated by a multi-discipline team made up of technical experts from the various NRC offices. If neces-sary, additional technical expertise will be obtained from National Laboratories and from technical consultants.
The duties, responsibilities and schedules to be I
2.
i followed will be formally established in an NRC Manual Chapter and associated supporting procedures. In cases where an Incident Investigation Team (IIT) is activated, the IIT will constitute the single NRC
- fact-finding investigation of the event.
- 3. Guidance will be developed and documented in the NRC 3
Manual Chapter regarding the significant operational events to be investigated by the IITs. It is Nurrently anticipated that the IITs will investigate approximately 2-3 events per year.
I i 4. Each IIT will be formally established by the EDO based on 4
recommendations from a Regional Administrator or
[
a Program Office Director. In order to ensure the maximum degree of independence for the IITs, each IIT will report directly to the EDO.
- 5. Each team leader will be selected by the EDO. The team l
leader will be at the SES level and, to the extent prac-l tical will not have had any significant direct involve-ment in the licensing or inspection of the subject plant.
l 6. The number and composition of each IIT will be established
! by the team leader from pre-approved rosters based on l the characteristics of the specific event to be investigated. Team members will be automatically relieved from existing duties for the duration of the investigation. Care will be taken to ensure that each team contains persons with detailed knowledge of the
The Comissioners subject plant (e.g., the Resident Inspector) and a sufficient number of persons who are independent of the licensing and inspection of the subject plant (e.g.,AEOD,RES). To the extent possible, team members will be selected on the basis of their tech-nical cr operations expertise, potential contributions to the event investigation, and their freedom from significant direct involvement in the licensing and inspection of the plant involved or activities directly associated with the event. Candidates for participation on IITs will be identified in advance on rosters to be maintained by AE00.
- 7. Candidates for team leaders and for IIT members will receive fonnal training in incident investigation. To the extent practical, this training will be completed before they are assigned to an IIT.
- 8. Procedures will be developed to ensure that sufficient information is provided to IE, NRR, NMSS, or the Regions to enable immediate action to be taken (e.g.,
- 9. Each IIT will prepare a single comprehensive report s which will focus on a description of the event,
, fact-finding, identification of the root cause(s) of
'the event, and findings and conclusions. The report will be issued simultaneously to the Commission and the EDO. Copies of the report will be placed in the PDR and will be forwarded to the ACRS for independent l
review. Specific procedures will be established for l
the EDO to initiate appropriate follow-on actions and
- to formally respond to the IIT report. The approval and implementation of resulting corrective action will follow existing procedures, including CRGR review.
- 10. IIT will emphasize the collection and documentation of factual information and evidence associated with the event. The resulting record will include, as appro-
! priate: documented statements of plant personnel l involved with or influencing the event; pertinent records and documents such as logs, strip charts, computer printouts, procedures, and maintenance manuals and histories; and other documentation such as photographs and subsequent test and inspection results.
- 11. Consideration will be given: to providing the capa-l bility to invite representatives from outside the NRC l (e.g., INPO, NSSS suppliers) to participate in the IIT
The Comissioners in.estigation; to providing subpoena power to the IIT; and to providing the authority to pre-empt parallel investigations by other organizations if they interfere with the IIT investigation.
- 12. Whenever an IIT is activated, an imediately effective Order or Confimatory Action Letter, as appropriate, will be issued to the affected licensee requiring that, within the constraints of maintaining plant safety, the equipment is left in the "as found" condition and information and data concerning the event are retained. Specific procedures will be established in the Order or Confirmatory Action Letter to permit the team leader to lift all or part of the order as soon as possible in order to minimize the impact on continued plant operation. Specific proce-dures will be established to ensure that at no time will a " freeze" order interfere with maintaining a plant in a safe and stable condition.
- 13. Investigations will begin as soon as possible after identification of the significance of the event, but consistent with the need to ensure that the plant is placed in a safe and stable condition. Specific procedures will be established to define the rela-tionship between the IIT and the NRC personnel on site N who are monitoring the plant to ensure that it is
,p(laced and Response e.g., Regional maintained in a safe and stable condition Team).
- 14. The IITs will be specifically directed to emphasize fact-finding and determination of probable cause and not to specifically search for violations of NRC rules and requirements in order to minimize any adversarial atmosphere during an investigation. Follow-on action regarding possible enforcement actions, based on factual infomation developed by an IIT investigation, I
will remain the resporsibility of IE and the Regions.
The information will also be provided to 01 and OIA, as appropriate.
- 15. AEOD will administer the Incident Investigation
- Program, including development of the NRC Manual l Chapter, and will provide necessary administrative support to the IITs.
- 16. It is currently expected that the IIT Manual Chapter and supporting procedures and personnel rosters will be prepared and approved on a timescale to allow implementation in early 1986.
l l 17. In addition to the investigation of significant operating events by IITs, events of lesser signifi-cance which may involve a generic safety concern or
The Comissioners '
important lesson of experience, will be investigated by regional-based personnel augmented by technical experts from headquarters program offices or con-tractors. Events warranting this augmented approach will be identified by the Regional Administrator or by a Director of IE, NRR, or NMSS and will be coordinated with the appropriate Regional Administra-4 tors. These investigations will also emphasize prompt 1
fact-finding, determination of root cause and
" freezing" of conditions. Added training on technical investigations will be conducted for the involved staff.
- 18. Procedures for condu:: ting augmented investigations of less significant events will be developed by IE, reviewed with other NRC offices and incorporated into the IE Manual. It is expected that these pro-cedures will be available and special training initiated in early 1986.
- 19. In the interim, should a significant event occur, the staff response will be consistent with the above policies and practices, to the extent practical.
1
Conclusions:
The changes in the NRC Incident Investigation Program described above incorporate the intent of the coments and recomendations made by the various groups (e.g. BNL, ACRS, OPE),regarding needed improvements in event investigation.
' The r'evised incident investigation program will ensure that NRC investigations of significant events are conducted in a thorough, structured and coordinated manner that j
' emphasizes fact-finding and determinatior, of probable cause. .
Finally as noted previously, the team leader and team members will be selected on the basis of technical compe-tence and potential contributions to the investigation. To the degree possible, the team will be largely staffed with individuals with no significant involvement with licensing and inspection activities associated with the event or plant. Thus, independence from previous licensing and i
inspection activities will be achieved. This revised program provides a substantial improvement in the way staff
' investigates significance events with a minimum of disrup-tion, increase in resources or realignment of existing office responsibilities.
Recomendation: That the Comission:
- 1. Approve the course of action described in this Comission Paper and in Enclosure 1. .
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The Comissioners 2. Note that a copy of this Comission Paper will be placed in the Public Document Room.
Scheduling: If scheduled on the Commission agenda, I recomend that this paper be considered at an open meeting. No specific circumstance is known to the staff that would require Comission action by any particular date in the near term.
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WilliaN.~Dircks Executive Director for Operations
Enclosure:
Draft Memo to C. J. Heltemes from W. J. Dircks Commissioners' comments or consent should be provided directly to the Office of the Secretary by c.o.b. Thursday, June 27, 1985.
Commission Staff Office comments, if any, should be submitted to the Commissioners NLT Thursday, June 20, 1985, with an infor-mation copy to thh Office of the Secretary. If the paper is of such a nature that it requires additional time for analytical review and comment, the Commissioners and the Secretariat should be apprised of when comments may be expected.
DISTRIBUTION:
Commissioners OGC OPE
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OCA OIA OPA REGIONAL OFFICES EDO ELD ACRS ASLBP l ASLAP l SECY l
MEMORANDUM FOR: C. J. Heltemes, Jr., Director Office for Analysis and Evaluation of Operational Data FROM: William J. Dircks Executive Director for Operations
SUBJECT:
IMPLEMENTATION OF A REVISED PROGRAM FOR THE i INVESTIGATION OF SIGNIFICANT OPERATING EVENTS i In order to ensure that the investigation of significant events is structured, coordinated, and formally administered, you are requested to develop the necessary guidance for an expanded program of event investigation. This guidance is to be consistent with the corrinitments and characteristics of the revised program for the investigation of significant events as defined in my paper to the Commission dated June , 1985.
1 Specifically, you are requested to:
3 1. Prepare an NRC Manual Chapter that will define the duties, respons-ibilities, and schedule for event investigation of significant events.
This Manual Chapter is to contain guidance regarding the significant operational events to be investigated by an Incident Investigation Team (IIT).
- 2. Prepare personnel rosters of candidate IIT leaders and members so that an IIT can be promptly established. These candidates should be preapproved by the Office Directors on the basis that if the individual is selected for IIT duty, he or she will be automatically relieved from existing assignments. \ ,
- 3. Develop appropriate training plans for candidate IIT leaders and members and provide assistance for arranging for such training to be conducted as soon as possible.
- 4. Prepare supporting procedures covering IIT activities. These procedures are to ir.clude the specific points and concerns identified in the Commission Paper.
t l 5. Work with ELD to draft suitable language ard procedures for issuing (and removing) an immediately effective Order or Confirmatory Action Letter requiring that, within the constraints of traintaining plant safety, equipment is left in the "as fcund" condition and information and data
! concerning the event are retained.
DRAFf
C. J. Heltemes , Jr. J
- 6. Investigate the need for and feasibility of providirg the capability to invite representatives frcm outside the NRC (e.g., INP0, NSSS suppliers) to participate in the IIT investigation; to prcviding subpoena power to the IIT; and to providing the authority to preempt parallel investigations by other organizations if they interfere with the IIT investigation.
You are requested to accomplish the above activities on a timescale to allow an IIT to be established in accordance with approved guidance and personnel rosters in early 1986.
3 William J. Dircks Executive Director for Operations s
N t LIT
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