ML20134L946
| ML20134L946 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 08/27/1985 |
| From: | Dircks W NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO) |
| To: | Asselstine, Palladino, Roberts NRC COMMISSION (OCM) |
| References | |
| NUDOCS 8509030478 | |
| Download: ML20134L946 (1) | |
Text
,_
NRt P D rL s
AUG 2 7 is a
MEMORANDUM FOR:
Chairman Palladino Distribution Commissioner Roberts NRC PDR' Commissioner Asselstine AE00 CF Commissioner Bernthal AE00 SF Commissioner Zech ED0 RF W. Dircks FROM:
William J. Dircks J. Heltemes Executive Director for Operations E. Rossi J. Roe
SUBJECT:
NRC DAVIS-BESSE TEAM COMMENTS ON T. Rehm EVENT FACT-FINDING METHODOLOGY li Enclosed for your information are comments from Ernie Rossi, leader of the NRC Team for the Davis-Besse event.
Dr. Rossi's comments are on the process and methodology and will serve to improve the instructions to the next NRC 4
Team and will be factored into the development of the formal procedures for theIncidentInvestigationProgram(IIP).
These comments are believed to be consistent with the concept and principles for the IIP'as discussed in my June 10, 1985 paper to you (SECY-85-208).
For the most part, they represent suggestions regarding the details of implemen-tation.
In order to thoroughly understand all of the lessons from the investigation of the June 9 event as they apply to future investigations, I have asked that other NRC orr?-izations involved also be solicited as to their views on the strengths and *,.aaknesses of the procedures used at Davis-Besse. This inquiry is also enclosed for your information.
($ignes William J.Dircks William J. Dircks Executive Director for Operations
Enclosures:
As Stated cc w/ enclosures:
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AUG 2 0 SBS MEMORAt1DUM FOR:
William J. Dircks
'E>acutive Director for Operations FROM:
Charles E. Rossi Leader of the 14RC Team on the Davis-Besse Event
SUBJECT:
NRC DAVIS-BESSE TEAM COMMENTS ON' EVENT FACT FINDING METHODOLOGY t
The team for the Davis-Besse event of June 9, 1985 was the first incident investigation under the staff proposed Incident Investigation Program.
This memorandum provides comments on the fact finding methodology for consideration
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in developing procedures for future team efforts.
The most important aspect of team fact finding efforts is that of collecting the information systematically with the development of a record of the team activities.
In this regard, two techniques used by' the team were particularly important and should be used for at least the more significant events by future teams.
These are:
1.
Formal interviews and meetings with transcribed records prepared by j
stenographers.
2.
Quarantining of equipment that malfunctioned during the event with troubleshooting performed in accordance with guidelines similar to those in Appendix B of the team's report (NUREG-1154).
The use of stenographers for all interviews and meetings, in the team's judgment, improved the quality of information obtained and minimized the probability of later misunderstandings concerning information provided to the team.
It also ensured a permanent record of information essential to a proper understanding of what happened and how equipment and personnel performed.
Tne troubleshooting gt.idelines ensured that the licensee sogld review and document pertinent past history with each piece of equiprent that malfunctioned.
Furthermore, the guidelines required analysis of the operation of the equipment during the event and the development of failure hypotheses before beginning any troubleshooting on the equipment.
The preparation of an individual " action plan" _for each piece of equipment that malfunctioned, as done during the Davis-Besse fact finding effort, ensured good documentation of information on the equipment which malfunctioned an'd, thus, provided permanent records on this aspect of the team efforts.
The team further believes that tests to duplicate malfunctions and tests to demonstrate the effectiveness of Documentation of c6rrective actions are critical in verifying root-causes.
the results of these activities is considered to be a good practice.
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J Willian J. Dircks,
The rost significant problem experienced by the team was defining (and j
limiting) the s~ cope of the fact finding efforts.
For future teams, the scope of'effert should be specifically limited to the event, the equipment which malfunctioned during the event, -the operator performance related to the event, and the underlying cause or causes of the event.
Plant design or licensee prcblems not related to the event should not be within the team's scope but; rather, should be handled by the responsible normal NRC organizations - the Regien, NRR, IE, etc.
Where troubleshooting efforts to determine root-causes of equipment malfunctions are going to extend over a time period of more than approximately two weeks, the team's scope should include only a review of the licensee's troubleshooting plans and root-cause hypotheses.
The followup of l-icensee work to perform the troubleshooting and ultimately to identify the u
roct-causes should be handled by the normal responsible NRC organizations.
For
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events such as Davis-Besse, the goal should be to complete a report on a time scale of one to two months.
The procedures to be prepared for future team efforts should clearly address these points.
3 Adninistrative support for the team's efforts was adequate.
However, an administrative assistant or project manager assigned full-time to the team would have been valuable.
Work space available for future teams should include a relatively separate work place for each team member with a telephone.
, Difficulty in promptly obtaining additional travel advance money when it became evident that the initial site visit would be longer than originally planned was
'a significant problem for two members of the team. contains a suggested list of topics which should be covered by procedures for incident investigation teams.
Where appropriate, comments have
. been provided. contains a list of items provided by Jim Lieberman and Steve Burns of OELD which should be considered when procedures for future teams are developed.
4 I would like to note that Region III personnel were very cooperative throughout the team effort.
They participated in meetings with the team and licensee, kent tne team informed of their. activities, and provided the team with clerical su: port.
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m Charles E. Rossi Leader of the NRC Team'on the Davis-Besse Event Enciosures:
As stated l
cc:
H. Denton, NRR J. Taylor, IE S Heltemes, Jr., AE0D Pegional Administrators l
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Topics Which Should Be Covered by Procedures For Incident Investication Teams 1.
Guidelines for determining those events which warrant dispatching a team.
2.
Selection of team members.
In general, team members should have a broad ur.derstanding of reactor safety and reactor transient behavior.
The procedure for selection of i
I team members should, however, address the need for expertise in areas such as human factors and specific equipment-hardware design.
The advantages of including a member on the team having direct reactor operating experience as a licensed operator should be considered.
3.
Scope of investigation.
4.
Handling' of quarantined equipment.
5.
Handling of transcripts.
The procedures should include provisions for overnight transcript preparation and cover access, review and release of transcripts.
The procedures developed for the transcripts related to the Davis-Besse event (see Enclosure 2) appeared to work well and should be considered for use by future teams.
6.
Team interface with normal NRC organizational elements.
Information feedback from the team to the normal NRC organizational elements should be from the Team Leader to one single point of contact within headquarters senior management and one single point of contact within the Region.
The Region contact should be an individual selected by the Region who is available at the site for liaison with the team.
A preliminary sequence of events should be developed and made available to other NRC organizational elements within the first week of team effort.
7.
Report Format.
The level of detail to be included in the report should be defined.
8.
Collection and listing of pertinent documentation.
The need for working copies of documents for team members as well as the maintenance o'f a record copy should be addressed.
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9.
Responsibilities of Team Leader.
i g-10.
Administrative Matters.
The need for an experienced administrative assistant assigned full-time to the team should be addressed.
Secretarial, public affairs, legal, and editorial support should be addressed.
11.
Provisions for rapidly ottaining contract technical assistance support.
Analysis support as well as on-site equipment expertise should be addressed.
12.
Training...
Team members need training on interviewing techniques and evaluating information obtained from interviews.
13.
Information Release Regarding an Event.
The source of factual information related directly to an event should be the team.
Presentations that are not made by the team on the specifics of an event should be limited to only that information provided by the team.
Such information should include the sequence of events and periodic progress reportsuon the team's efforts.
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Enc 1csure 2 i-Uuly 25, 1985 i
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' Note. to 'Er6ie Rossi; IE!
LESSONS LEARNED FROM DAVIS-BESSE INVESTIGATION As I mentioned yesterday, Steve Burns and I have discussed lessons learned from Steve's involvement with your team.
I have enclosed a note to files that we have prepared on this issue which mhy be of assistance to you.
Please call me if I can provide any further assistance.
Jim Lieberman
Enclosure:
as stated cc:
J.'Heltemes
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July 25, 1985 Note to files DAVIS-BESSE INCIDENT INVESTIGATION
" LESSONS LEARNED" The following list is meant to highlight some of the legal procedural, and administrative problems that occurred during the NRC Fact Finding Team's incuiry into'the June 1985 Davis-Besse loss-of-feedwater transient. These issues do not necessarily reflect matters that actually arose during the Term's efforts from my vantage point, but represent issues that arose or I saw as potentially arising during similar task forcs efforts.
Some of the issues may require the establishment of specific policy guidance and imple-menting procedures; others may require training of Team members; others nay just need to be planned for to support the Team's efforts:
1.
Transcription of interviews and meetings
- whether to take transcripts (the D-B Team found it useful)
- availability of transcripts to interviewees, licensee, and the public (note attached procedure developed for the D-B effort)
- handling of transcript corrections
- turnaround time from reporting service for transcripts (whether to order overnight vs. 2-day service)
- should individuals be permitted to tape record interviews or meetings?
2.
Attendance of third parties at interviews 1
- what policy should be followed?
Is the new OI policy a good starting point?
- what steps should be taken to deal with a multiple representation issue (i.e., company counsel who also purports to represent individual operators)?
- what steps should be taken to dissuade individuals from having company ' counsel or company management accompany them in an interview?
- what should be established "on the record" about the presence t
of third parties at an interview?
- the representational relation between the third party and the interviewee should be established ack n m~1x,o m nc.?atays rm
. 3.
Collection.of documents
- procedures for tracking and " logging in" data and documents should be established
- instructions should be developed to assist Team members in identify-ing documents "on the record" during the transcribed interviews and including them as " exhibits" to the interview
- guidance should be developed on sharing documentation with the licensee'(i.e., whether to follow the policy ~ guidance on draft inspection reports or whether to permit sharing of working docu-ments so long as they are preserved.)
4.
Powers of the IIT
- should'the IIT be given subpoena power, power to administrator oaths and affirmations, confirmatory action letters, or orders and, if so, should form documents be prepared in advance?
- a freeze on plant equipment and documentation should be established as well as the rules for its relaxation
- if the Team does not have such powers, what standing arrangements should be made to ensure the prompt availability of compulscry process such as identified above?
5.
Interface with other NRC organizations
- arrangements for dealing with press inquiries need to be made; the responsibility shifted in D-B from the Region to headquarters
- interface with headquarters program offices need to be established -
a single point of contact would appear preferable
- interface with regional inspectors efforts needs to be established as well as the guidelines as to the extent to which the Team will share information with the Region or rely on the Region for its development
- provisions need to be made for additional technical and admini-strative assistance for the Team.
The job of assimilating in-formation and reaching conclusions about its significance may be
.too much for the four Team members to accomplish by themselves in a week or two. Administrative support was provided to D-B through the Region; and administr'ative assistant to handle clerical and administrative matters woulo be useful.
- what legal support should be provided on-site? Until Team members feel comfortable with handling the formal interview process, the procedural and legal ramifications concerning the handling of the interviews, and the like, legal support at the site may be useful.
- arrangements to inform 01 and obtain 01 support shculd be established.
6.
_I_nterface With the Licensee and Other Industry Oraanizations
- a main point of contact with the Licensee should be established for arranginy~ meeting times and obtaining documehts, etc.
- contacts with ver. dor representatives and IllP0 Steve Burns
Attachment:
Review and Availability of Transcripts O
EEVII".' AND AVAll>.EII,ITV 0? TFJJ:5CRIFTS Th tiVRC Tac: Finding Tear has had interviews and neerings transcribed to-assis:.he Tea in cendue:ing its review cf the June 9,1955, transient a'
- h e Dav.4 s-m. esse Nuc,. ear -cuer Station.
the. tea: :.ntends to mak.e transcripts cf interviews 'and meetings available for review under Ibe followi=g guidelines:
1.
A copy of the tran' script vill be =ade availab15 initially for rev_, ev enly to :.nc:.v:. duals v.no nave ceen :.nterviewed.
Individuals
=ay read enly their tranneript, =ake notes, and consult with others while revieving the transcript.
Eevever, they =:ay nor
=ake cepies cf the transcript and vill ne be permitted to keep the transcrip until a later ti=e.
2.
Individuals =ay =ake corrections or suggest clarifications to their ansvers which will be attached, to the ' official transcript.
Corrections er clarifications should be =ade on the correction sheets that vill be provided rather than en the transcrip itself.
If anyene vishes to speak further with the Fact Findino.
c Teat, the Tet= vill be available to conduct further interviews.
Further interviews vill also be transcribed.
3.
The Fact Finding-Tea = intends to give each individual interviewed a copy of the transcript of his interview for his personal retention and use af ter the conclusien of. all the interviews and after each
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individual has had an opportunity to cofrect his transcript.
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A: the sa=e time that those interviewed are provided a copy of their transcripts, the Tea = intends to =ake the transcript "J
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' available to the public and steps ' vill be taken to u o===1:
the transcripts to the NRC's Public Document Roo=s.
5.
Ir.rscrints cf =ee:ings between the tae: ::.n,ing
.t eam and ol ec.o t
Edisen Cc=pany vill be available to NEC personnel (including Regica III) and Toledo Edisen Cc:pany personnel for review.
Toledo Edison Cc=pany =ay suggest correctic=s er clarifications, if appropriate, which vill be included with the efficial transcript.
Cerrecticns er clarificaricas should be =ade on the correction..
sheets that vill be provided rather than en the transcript itself.
6.
Ccpies of the meeting ::anscripts vi'l be released to Toledo Edison Cc=can' f or its ret entien af ter the Iea= has substantially con-cluded its efforts at the site.
The ::anscripts will 'oe =ade available to the public unless the licensee has =ade a recuest f or protec:icn of proprietary inf or=atics in the tra= scripts in accordance with NRC regulations.
O NRC Tac: Tinding Tean 06/17/85
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'j WASHINGTON, D. C. 20555 k.....,e8 August 22, 1985 MEMORANDUM FOR:
Harold R. Denton, Director, NRR James M. Taylor, Director, IE Robert B. Minogue, Director, RES John G. Davis, Director, NMSS Regional Administrators FROM:
C. J. Heltemes, Jr., Director Office for Analysis and Evaluation of Operational Data
SUBJECT:
LESSONS FROM THE DAVIS-BESSE INVESTIGATION EFFORT The purpose of this memo is to solicit your views and suggestions on how the Incident Investigation Program (IIP), as used for the Davis-Besse event, can be improved for future Team efforts.
In this regard, the leader of the NRC Team on the Davis-Besse event, Ernie Rossi, recently identified to the EDO a number of comments for consideration in developing procedures for future Team efforts (see enclosure).
These comments also include a number of comments and con-siderations by Steve Burns, the ELD advisor to the Team.
The NRC Davis-Besse Team served a valuable function in helping to structure and define the' investigative process, approach and methodology.
Thus, I request your comments on whether the next Team should:
1.
Have basically the same scope and charter, and the resulting report be similar in terms of schedule, coverage, and depth.
Follow the same basic practices of: (a) interviewin key personnel; (b) developing a detailed sequence of events; and (g) analyzing and 2.
c evaluating what happened to identify root cause hypotheses.
3.
Develop a record of the Team's activities through transcribed interviews and meetings and by use of cameras and recorders.
The control and correction of transcripts could follow the same procedures.
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Agree on the quarantine equipment that malfunctioned during the event and monitor licensee activities on troubleshooting this equipment using similar guidelines to those developed for the Davis-Besse event.
5.
Disband following completion of the report and pertinent briefings.
Follow-on actions would be defined in a similar manner used for Davis-Besse, and implementation would be by the normal responsible NRC organizations using standard procedures.
Other actions which you may want to consider in addition to those noted by Ernie Rossi include such items as:
1.
Improving the information flow by asking the NRC Team to issue a daily PN and by holding periodic conference calls.
2.
Providing an individual trained in human factors to each Team in addition to individuals skilled in operations, systems, and components.
3.
Increasing the number of court reporters to two in order to allow parallel interviews and to complete this phase more quickly.
The sequence of events could then be issued more quickly.
Your comments and suggestions on the strengths and weaknesses of the process for fact-finding, as used at Davis-Besse, will be factored into the instructions and procedures for the next Team.
Please let me know if I can provide any additional information or assistance.
Wr
- Heitemes, Director O
for Analy and Evaluation of Operational Data
Enclosure:
As Stated