ML20137G698
| ML20137G698 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 08/22/1985 |
| From: | Heltemes C NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | Harold Denton, Minogue R, Taylor J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE), Office of Nuclear Reactor Regulation, NRC OFFICE OF NUCLEAR REGULATORY RESEARCH (RES) |
| References | |
| NUDOCS 8508270368 | |
| Download: ML20137G698 (2) | |
Text
n-Un e POW 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 Nf,,
ieam on the Davis-Besse event, Ernie Rossi, recently identified to the ED0 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 i
be similar in terms of schedule, coverage, and depth.
2.
Follow the same basic practices of: (a) interviewing key personnel; (b) developing a detailed sequence of events; and (c) analyzing and evaluating what happened to identify root cause hypotheses.
3.
Develop a record of the Team's activities through transcribed interviews and meetings af:d by use of cameras and recorders.
The control and correction of transcripts could follow the same procedures.
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4.
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 canner 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 strength: 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.
onginal S:gned by C. J. He!temes, Jr.
C. J. Heltemes, Jr., Director Office for Analysis and Evaluation of Operational Data
Enclosure:
As Stated Distribution:
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AUG 2 0 95 MEMORANDUM FOR:
William J. Dircks Executive Director for Operations
'd 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 k
The team for the Davis-Besse event of June 9,1985 was the first incident investigatior, under the staff proposed Incident Investig'ation 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, stwo 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 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 rtenographers 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 eouipment and personnel performed.
The troubleshooting guidelines ensured that the licensee would review and document pertinent past 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 an'd, thus, prcvided 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.
Y
,% M M
William J. Dircks.
The most significant problem experienced by the team was defining (and limiting) the s~ cope 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 tne 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 organizations - 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 troublesnooting and ultimately to identify the ro'ot-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 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 procedu'es for incident investigation teams. Where appropriate, comments have r
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.
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, kept the team informed of their, activities, and provided the team with clerical support snY8h*f M
Charles E. Rossi Leader of the NRC Team'on the Davis-Besse Event
Enclosures:
As stated cc:
H. Denton, NRR J. Taylor, IE WHeltemes, Jr., AE0D Regional Administrators
Topics Which Should Be Covered by Procedures For Incident Investigation 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 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 tne 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 m'aintenance of a record copy should be addressed.
9.
Responsibilities of Team Leader.
2-10.
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 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.
Srch information should include the sequence of events and periodic progress reports on the team's efforts.
e 4
..I duly 25, 1985
? Not'e;. to 1951 ' Ros'si;* IEi 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.
A A Jim Lieberman
Enclosure:
as stated cc:
J.'Heltemes S
e
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 inquiry 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 may 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
- 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 of third parties at an interview?
- the representational relation bet' ween the third party and the interviewee should be established
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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 compulsory p,rocess 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 necds 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 l
- provisions need to be made for additional technical and admini-strative assistance for the Team.
The job of assimilating in-j 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 cierica!
and administrative matters would be useful, i-
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s'.
- 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 OI and obtain 0I support should be established.
6.
Interface With the Licensee and Other Industry Oroanizations
- a main point of contact with the Licensee should be established for arrangin~g" meeting times and obtaining docunieh~ts, etc.
- contacts with vendor representatives and INP0 Steve Burns
Attachment:
Review and Availability of Transcripts 4
e 9
9 e
b
ise REVIEW AND AVAII.A311.ITY OF TFJ.NSCRIPTS The NRC Tact Finding Team has had interviews and meetings transcribed to-assist the Team in conducting its review of the June 9,1985, transient a'r the Davis-3 esse Nuclear Power Station.
The Team, intends to nake transcripts of interviews 'and meetings available for review under the following guidelines:
1.
A copy of the tran' script vill be made availabl5 initially for review only to individuals who have been interviewed.
Individuals
=ay read only their transcript, make notes, and censult with others while revieving the transcript.
Eovever, they miay not
=ake copies of the transcript and vill not be per=itted to keep.
the transcript until a later time.
2.
Individuals may take corrections or suggest clarifications to their ansvers which vill be attached, to the ' official transcript.
Corrections or clarifications should be made on the correction sheets that vill be provided rather than on the transcript itself.
If anyone wishes to speak further with the Fact Finding Tea =, the Teze vill be available to conduct further interviews.
Further interviews vill also be transcribed.
3.
The Fact Finding-Team intends to give each individual interviewed a copy of the transcript of his interview for his personal retention and use af ter the conclusion of. all the interviews and after each individual has had an opport' unity t'o coriic~t his transcript.'
~
4 At the same time that those interviewed are provided a copy of their transcripts, the Team intends to =ake the transcript *r
' available to the public and steps ' vill be taken to tr= m=-it the transcripts to the NRC's Public Document Roo =s.
e 5.
Trnscrints of meetings berdeen the Fact Finding Tean and Toledo Edison Conpany vill be available to NRC personnel (including Region III) and Toledo Edisen Co=pany personnel for reviev.
Toledo Edison Co=pany =ay suggest correctiens or clarifications, if appropriate, which will be included with the official transcript.
Corrections' or clarifications should be =ade on the correction.{..:
sheets that vill be 7:
ided rather than on the transcript itself.
6.
Copies of the meeting transcripts vC1 be released to Toledo Edison Conpany f or its reten-icn after the Tez= has substantially con-cluded its efforts zt the site.
The trans:-ipts vill be =ade available to the pui~ic less the Jcensee has =ade a request
}
f or protection of p r--ieta-y inf on u: ion in the tra=scr.ipts in accordance with NRC regu h tions.
NRC Fact Find.ir: Team 06/17/85
DIRICTIONS FOR MAKING CORRICTIONS r
.e s
If you have any corrections that you wish to make on vour transcript, please do so on the f ollowing race following fashion:
in the
.I dicate the page of the correction, the line number, and then the change to. be pade,and the reason f er making the change.
Date and sign all correc-tion pages that correspond with your
.tr ans crip t.
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