ML20137D173

Comments on Fact Finding Methodology for Use in Developing Procedures for Incident Investigation Program Efforts,Based on Investigation of Facility 850609 Event.List of Topics to Be Covered by Procedures Encl

ML20137D173
Person / Time
Site:	Davis Besse
Issue date:	08/20/1985
From:	Rossi C NRC - TEAM ON DAVIS-BESSE EVENT
To:	Dircks W NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO)
Shared Package
ML20137D175	List: ML20137D173 ML20137D188 ML20137D204
References
NUDOCS 8508220413
Download: ML20137D173 (4)

Text

l UNITED STATES

.r,,[ "j' % W') g NUCLEAR REGULATORY COMMISSION pj WASHINGTON. D. C. 20555 wAf AUG 20 W MEMORANDUM FOR: William J. Dircks Executive Director for Operations -

FROM: Charles E. Rossi Leader of the NRC Team on the Davis-Besse Event

SUBJECT:

NRC DAVIS-BESSE TEAM COMMENTS ON EVENT FACT FINDING METHODOLOGY.

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 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:

1.1 Formal interviews and meetings with transcribed records prepared by 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 l

judgment, improved the quality of information obtained and minimized the i 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.

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The troubleshooting guidelines ensured that the licensee would review and doctment pertinent rast history.with each piece of equipment 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 and, 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 corrective actions' are critical in verifying root-causes. Documentation of the results of these activities is considered to be a good practice.

8508220413 850820 PDR ADOCK 05000346 S PDR

William J. Dircks f l The most significant problem experienced by the team was defining (and limiting) the scope of the fact finding efforts. For future teams, the scope of effort 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 problems not related.to the event should not be within the team's scope but, rather, should be handled by the responsible normal NRC organization - the Region, 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 licensee work to perform the troubleshooting and ultimately to identify the root-causes should be handled by the normal responsible NRC organizations. For 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.

! Administrative support for the team's efforts was adequate. However, an 1 administrative assistant or project manager assigned full-time to the- team 1 would have been valuable. Work space available for future teams should 1- 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 twa members of the team.

Enclosure 1 contains a suggested list of topics which should be covered by-

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procedures for incident investigation teams. Where appropriate, comments have

been provided. Enclosure 2 contains a list of items provided by Jim Lieberman and Steve Burns of~OELD which should be considered when procedures for future

j. teams are developed.

I would like~to note that Region III personnel were very cooperative throughout i the team effort. They. participated in meetings with the team and licensee, kept the team informed of their activities, and provided the team with clerical support.

[

Charles E. Rossi Leader of the NRC Team on the Davis-Besse Event

Enclosures:

As stated

.l cc: H. Denton, NRR J. Taylor, IE' l C. Heltemes, Jr. , AE0D

. Regional Administrators D tribution:

S CERossi, IE EAB R/F ELJordan, IE PDR DEPER R/F GHolahan, NRR LBell, TC J8eard, NRR JLieberman, ELD WLanning, AE00 SBurns, ELD

.- l Enclosure 1 Topics Which Should Be Covered by Procedures For Incident I.1vestigation 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 understanding of reactor safety and reactor transient behavior. The procedure for selection of 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 las a licer. sed operator should be considered.

l 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 of a record copy should be addressed.

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9. Responsibilities of Team Leader.

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.

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11. Provisions for' rapidly obtaining 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 reports on the team's efforts.

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