ML20141E546
| ML20141E546 | |
| Person / Time | |
|---|---|
| Issue date: | 12/31/1985 |
| From: | NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| Shared Package | |
| ML20141E542 | List: |
| References | |
| PROC-851231, NUDOCS 8601080141 | |
| Download: ML20141E546 (19) | |
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i INCIDENT INVESTIGATION PROGRAM PLAN i
t Prepared By:
Incident Investigation Staff Office.for Analysis and Evaluation of Operational Data December 1985 i
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8601000141 851231 PDR MISC
- B601080133 pyg
l TABLE OF CONTENTS 4
Page Number 1.0 Purpose.......................................................... 1 ~
2.0 Incident Investigation Program................................... 1 3.0 . Program Activities and Schedules Related to Investigation Program.......................................................... 1
- 3.1 Activities Required for Initial Implementation of the IIP................................................. 2 3.1.1 Preparation of Manual Chapter NRC-0513, "NRC Incident Investigation Program".................................. 2 3.1.2 Preparation of Personnel Rosters........................ 2 3.1.3 Define and Conduct Training for IIT Members............. 3 3.1.4
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Development of Standard Confirmatory Action Letter or Order Related to Equipment and Data. . . . . . . . . . . . . . . . . . . . . 4 3.1.5 Identification of IIT Administrative Requirements....... 4 3.1.5.1 Travel Arrangements..................................... 4
, 3.1.5.2 Stenographers........................................... 4 1 3.1.5.3 Eq u i pme n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3.1.6 IIT Manua1.............................................. 5 3.2 Long-Term Activities Not Required for Initial IIP Implementation.......................................... 7 3.2.1 Participation by Other Organizations. . . . . . . . . . . . . . . . . . . . 7 3.2.2 Subpoena Power and Power to Administer Oath and A f f i nn a ti o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 3.2.3 Authority of IIT to Pre-empt Parallel Investigations.... 8
- 3.2.4 Routine Testing for Drugs and Alcohol . . . . . . . . . . . . . . . . . . . 8 3.2.5 Unsolicited Information from Plant Personnel............ 8 3.2.6 Develop Procedures for Application of the IIP to Nonreactor Incidents.................................... 9 3.3 -AIT Procedures.......................................... 9 4.0 Organization..................................................... 9 5.0 Required Resources............................................... 10 5.1 Trave 1.................................................. 10 4
5.2- T ra i n i n g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 5.3 Program Support......................................... 10
- 5.4 NRC Personnel (FTE)..................................... 11
! 6.0 Schedule......................................................... 11 i
7.0 References....................................................... 14 Appendix............................................................... 16 r.
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J-PROGRAM PLAN FOR FISCAL YEAR 1986 INCIDENT INVESTIGATION STAFF (IIS) 0FFICE FOR ANALYSIS AND EVALUATION OF OPERATIONAL DATA (AE0D) 1.0 PURPOSE '
The purpose of this Program Plan is to define the activities and planned accomplishments requirec' to implement the NRC Incident Investigation Program (IIP) described in SFCY-85-209 (Ref. 1). The goal of this plan is to have'all of the procedures, training, equipment, etc., in place by July 31, 1986 to fully support an Incident i m estigation Team (1IT) for a reactor incident. IITs established prior to t. hat tii.e will use the procedures, etc. , established by this plan, to the extent that they are developed. Similar guidance will be developed for response to a non-reactor incident, including personnel rosters and procedures. This revised and expanded guidance will be developed and in place by March 31, 1987.
Background related to the establishment of the NRC Incident Investigation Progrsm is described in the Appendix.
2.0 INCIDENT INVESTIGATION PROGRAM (IIP)
The IIP is intended to upgrade the NRC investigation of significant events and to assure that the investigation 's time 'y, thorough, coordinated and formally administered. The scope of the IIP incluaes the investigation of significant operational events involving reactor and nonreactor activities licensed by the NRC.
The primary objective of the IIP is to enstre that operational events are investigated in a systematic and technically sound manner to gather information pertaining to the root causes of the events, including any NRC contributions or lapses, and to provide appropriate feedback regarding the lessons of experience to the NRC, industry, and the public.
By focusing on root causes of operating events and identification of associated corrective actions, the results of the IIP process should improve nuclear safety by ensuring a complete technical and regulatory understanding of significant events. The IIP has two investigatory responses based on the safety significance of the operational events. Both involve responses by an NRC team to determine the circumstances and causes of an operational event.
For a more significant event, an Incident Investigation Team (IIT) will be dispatched by the EDO to investigate the event in a manner similar to the NRC response to the Davis-Besse event. The response to less significant operational events are designated Augmented Investigation Teams (AITs) which involve a regional directed team complemented by Headquarters personnel.
3.0 PROGRAM ACTIVITIES AND SCHEDULES RELATED TO INVESTIGATION PROGRAM In order to ensure that the investigation of events 15 structured, coordinated, and formally administered, AEOD has undertaken a number of activities towards developing the necessary guidance documents for an expanded program of significant event investigation. This section identifies the activities associated with the IIT that will be completed during FY 1986-1987.
1 3.1 ' Activities Required For Initial Implemantation of the IIP The following activities will be completed by July 31, 1986 and the products will be used for all IITs established after that date.
f 3.1.1 Preparation of Manual Chapter NRC-0513, "NRC Incident Investi- '
gation Program" l
A new'NRC Manual Chapter will be prepared by AEOD that will ;
define specific objectives, responsibilities, and authorities, and establish basic requirements for planning, investigation, and follow-on actions to be taken in response to significant operational events involving NRC reactor and nonreactor licensees.
The manual chapter will define the agency wide program, including
] the scope and functions of individual offices for both Incident Investigation Teams and Augmented Investigation Teams. Included in the manual chapter will be guidance on the nature and type of events warranting an IIT or an AIT.
3.1.2 Preparation of Darsonnei Rustars l The IIS will develop and maintain two personnel rosters of candidates for p~rticioation a in IITs. The rosters may also be i
used to select team members for AITs. One roster will include only SES level personnel from which the EDO, with AEOD assis-tance, can select an IIT leader. The other roster will include
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senior personnel who may serve.as expert members on the IIT. ;
i AE00 will identify candidates for membership on-the IITs and obtain office review and comments. Background _information will i be developed for each candidate that includes areas of exper-3 tise and work activities related to licensed facilities.
! Arrangements will be made to ensure appropriate training '
is provided and necessary security clearances are obtained.
Qualifications and characteristics of team leaders include:
SES level employee.
Broad knowledge of nuclear technology, operating safety practices and procedures, operation and design of power !
reactors or fuel cycle facilities, NRC policies and !
procedures, and incident investigation.
Demonstrated administrative and management abilities in problem solving and meeting ~ schedules adequate to independently direct the efforts of numerous staff personnel working in many technical disciplines for 4
assigned investigation teams.
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- Skill at communicating complex technical information to such diverse groups as the Commission, staff engineers and management, utility engineers and management, the press, and members of the public.
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- The qualifications and characteristics of expert members of an 3 IIT include technical expertise in one or more of the disciplines
- represented in nuclear power plant design and operation with a
broad understanding of reactor systems and safety or nuclear l material safety and safeguards. They must have demonstrated _
ability to solve problems and produce an acceptable written '
report within a demanding schedule. The roster of candidates will be categorized according to disciplines and areas of special expertise, including engineering (e.g., reactor systems, electrical, instrumentation and control), operations, human factors, health physics, and safeguards and security.
3.1.3 Define and Provide Training for IIT Members Each candidate on the team leader roster and expert member roster will receive formal training in incident investigation.
, To the extent possible, training plans will take advantage of 4
existing courses related to incident investigation.
4 Discussions are being held with representatives of NTSB, FAA, and other organizations (Ontario Hydro) to identify appropriate 3
courses and their availability. In addition, the IIS will hold an IIT seminar describing the IIP and its procedures. Thus, IIT training might include the following:
IIP overview Accident investigation (MORT)
Interviewing techniques Legal /01/01A aspects Accident investigation perspectives NTSB 1 -
Davis-Besse IIT
. SONGS IIT IIT procedures Simulated IIT exercise
- At this time, it is estimated that personnel listed on the rosters will receive approximately 2-staff weeks of training
,_ before participating in an IIT. Initially, IITs may be formed with members who have not completed all IIT training. However, eventually all IIT members will have completed the training
- before assignment to an IIT.
1 Training may be~ budgeted for by AE00, with coordination from ADM, and then will be transferred to ADM/MDTS for administra-tion.
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3.1.4 Development of Standard Confirmatory Action Letter or Order
- Related to Equipment and Data The purpose of this activity is to prepare standardized language as input into a Confirmatory Action Letter (CAL) or Order that, ,
within the constraints of maintaining plant safety, equipment -
be -left in the "as found" condition and information and data concerning the event are retained.
The IIS will work with ELD and other offices to draft suitable language and procedures for issuing and removing an immediately effective Order or CAL. The IIS will develop procedural guidance for the IIT's handling of " quarantined" equipment during its investigation. The procedure will address the-identification of equipment, removal of equipment from the quarantined list, regional assistance in providing oversight of the troubleshooting activities, required documentation of root causes, etc.
3.1.5 Identification of IIT Administrative Requirements The purpose of this activity is to identify, establish, and maintain administrative support for the IITs.
- 3.1.5.1 Travel Arrangements The Incident Investigation Staff (IIS) will develop a
' procedure to ensure that all travel arrangements are completed in a_ timely and complete manner. It is currently planned that all travel associated with an IIT will be' funded by AE00. This activity includes:
Ability to process travel-authorizations and obtain travel advances on short notice regardless of day
, or time. The use of credit cards will be evaluated.
Determining the proximity of.the major airports and
- ' available lodging to sites. The IIS will develop a computerized listing of reactor site addresses and s
directions from a major airport, Ability ~to process travel claims in a timely fashion. 1 1
3.1.5.2 Stenographers !
This activity will involve coordination with the ASLB 1
Panel which administers the NRC contract for court reporters. Funds will be budgeted by AEOD and transfer-red to ASLBP as needed. Control of funds will be i maintained in AE00. Arrangements will be made to ensure overnight delivery of the transcribed interviews to the team at the site.'
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3.1.5.3 Egiipment This activity will identify and obtain all equipment and supplies required by the IIT to perform its investi-gatior. The equipment identified to date includes ..
cameras and accessories, tape recorders, and trans- -
cribiag equipment. An additional task is an evaluation of the need for a portable IBM-PC for the IIT while onsite.
3.1.6 IIT Manual This activity involves the development and compilation of procedures that govern and guide the IIT. The procedures will draw on the experience. gained in the Davis-Besse and the San Onofre IIT investigations and other pertinent investigations.
In response to a memorandum (Ref. 9) from C. J. Heltemes, Jr.,
Program Office Directors and Regional Administrators provided comments (Refs. 10 to 19) that will be used in preparing the IIT procedures. In addition, the comments provided by the Davis-Besse team in Reference 20 will be used in developing the procedures.
Issues that will be addressed in the IIT Procedures Manual will include:
- Conduct of Investigations Responsibilities of Team Leader Specific responsibilities of the team leader including directing / managing team, focusing investigations, speaking for IIT, participating in press conferences, preparing status reports, meeting schedules, etc.
- Work plan outlining execution of responsibilities.
- Communications / Interfaces Requirements for timely flow of information and for the IIT as single source of incident informa-tion.
- Headquarters and region interface contacts and responsibilities.
Interfaces between the IIT and the regions, headquarters, press, licensee, and other agencies.
- Unsolicited information from plant personnel.
Interfaces and coordination with other organiza-tions, e.g., INPO.
- Requirements to safeguard communication of sensi-tive information.
Development and coordination of access / clearance rosters.
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Scope of Investigation / Schedule
- Guidance for the investigation.
Major milestones.
- Guidance for requesting additional expertise (staff or contractors).
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- Transcripts
- Guidance for conducting interviews and selecting interviewees.
Guidance for handling the transcripts and access by other parties.
Attendanc? of third parties at interviews.
Guidance for handling anc: safeguarding the tran-scripts and permitting access by other parties.
Records and Documentation Need to account for documents and data.
- Guidance for accepting, referencing, and sharing draft documents.
Identification of official records.
Guidance for safeguarding records and documents containing sensitive information.
Access and retrieval of documents generated and collected.
Access to other data bases.
Archival requirements.
- Document management support.
Reproduction, filing and distribution.
Treatment of Quarantined Equipment Guidance for identifying equipment for quarantine.
Guidance for developing troubleshooting plans.
Task action plans for determining root causes of equipment failures.
Guidance for quarantined equipment that is addres-sed by technical specifications.
- Role of regional office in oversight of licensee troubleshooting root causes of equipment failures.
Procedure for use of third party examination equipment.
- Report Preparation Administrative procedures for preparation.
An outline, including use of appendices.
- Editorial assistance and typing. :
Need to protect draft versions.
- Review process.
Distribution.
Timing / criteria for release.
- Commission /ACRS Briefings
- Team leader presentation.
- Release of report.
ED0 Followup Procedures ~
- Development of staff followup actions.
3.2 Long-Term Activities Not Required for Initial IIP Implementation The following long-term activities will be completed after July 31, 1986. The resolution of these issues will be incorporated in IIP procedures.
3.2.1 Participation by Other Organizations The objective of this activity is to investigate the possibility of other organizations such as INPO, NSAC, vendors and National Laboratories participating in IITs.
The willingness of third party organizations to participate in IITs should be explored.
The extent and type of participation and associated pro-cedures should be defined.
AE0D will take lead on this item.
3.2.2 Subpoena Power and Power to Administer Oath and Affirmation The objective of this activity is to~ determine what powers the IIT should possess and under what conditions or circumstances they need-such powers. The tasks involved in resolving this issue include:
Identify situations that warrant subpoena power (e.g. ,
licensee personnel refuse to be interviewed, licensee or its contractors withhold reports or data).
Determine whether the IIT should be given subpoena power or whether a third party could perform this function.
Evaluate the need for sworn depositions versus transcribed interviews for obtaining information related to personnel actions.
ELD will be requested to take the lead in completing this activity.
3.2.3 Authority of IIT to Pre-empt Parallel Investigations The objective of this activity is to evaluate the feasibility of and necessity for the IIT to request, direct, or order other investigations of the event to terminate their activities. -
Such an action may be necessary if a parallel investigation was '
delaying or otherwise adversely affecting the IIT investiga-tion. This activity primarily addresses concurrent industry or licensee investigations because SECY-85-208 clearly states that the IIT will-be the single NRC investigation. At Davis-Besse, parallel investigations performed by industry groups did not interfere with the activities of the NRC fact-finding activities.
The tasks involved in this activity are:
Evaluate the circumstances where parallel inv'estigations may constitute interference with the IIT.
Determine the legal bases that the IIT must possess to pre-empt parallel investigations.
ELD will be requested to perform the legal analyses for such a requirement.
3.2.4 Routine Testing for Drugs and Alcohol This activity addresses the issue of whether the IIT s ope of investigations should provide for testing for the presence of drugs and alcohol of licensee personnel involved in an incident, particularly those that involved significant human factor questions. The Federal Aviation Administration and the Federal Railroad Administration have requirements for testing for drugs and alcohol. This activity deals with a potentially controver-sial issue and is related to " Fitness for Duty."
The tasks involved with this issue are primarily legal in nature and the resolution of this issue will involve:
- Determine the status and relationship to ongoing NRC activi-ties.
Evaluate whether a. drug / alcohol testing program should be incorporated within the IIP (e.g., voluntary testing, voluntary licensee requirement for testing, rulemaking, apply existing or proposed requirements).
ELD will be requested to perform the legal analyses for such a requirement.
3.2.5 Unsolicited Information From Plant Personnel This activity is to assure that there are means for IITs to receive unsolicited information, perhaps anonymously, from plant personnel. The Davis-Besse team interviewed primarily
operators and their supervisors. However, there may be person-nel who possess relevant information concerning the event or circumstances existing prior to the event and who would not normally be identified for an interview.
Identify and evaluate methods for obtaining relevant informa-tion from licensee employees on a voluntary basis.
Evaluate whether confidentiality is necessary and how it could be achieved.
3.2.6 Develop Procedures for Application of the IIP to Nonreactor Incidents This activity involves the development and revision of IIP guidance, including IITs and AITs, to investigate incidents at i
nonreactor facilities (e.g. , radiography incidents, incidents at fuel fabrication facilities, medical misadministrations).
It is anticipated that specific additional guidance may be necessary including implementing procedures.
3.3 AIT Procedures IE will prepare separate AIT procedures which will be incorporated into.the IE Inspection Manual.
The development and implementation of the AIT procedures will be completed by July 31, 1986 in coordination with the IIT. These ,
, -procedures will be used for all AITs established after that date. A draft procedure has been developed and transmitted for interim use.
Consistent with present practice, the program office supplying the manpower to augment the regional response also supports the indi-i vidual's travel and per diem costs.
4.0 ORGANIZATION i An Incident Investigation Staff (IIS) was established as an organizational element with AE0D. The staff includes a Chief, a Management Assistant, and an Incident Investigation Engineer.- Wayne Lanning was selected as Chief of IIS and reports directly to the Director of AEOD. Recruitment activities are
. focused on selecting the Management Assistant and Incident Investigation i Engineer which should be completed in February 1986.
The IIS will develop policy, program requirements, and procedures for IIT investigations of significant operating events. An IIS staff member will accompany each IIT to provide administrative support, liaison and technical guidance to ensure that the IIT activities are consistent with established procedures and coordinated with NRC offices and other organizations. The IIS will maintain and integrate plans, procedures, team rosters and training, and coordinate staff activities to achieve IIP objectives.
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The proposal for the composition of the IIS included an additional incident investigation engineer and a secretary, but these positions were not budgeted.
Hence, AEOD will provide additional support for the IIS, particularly during early stages of IIP development and during an IIT investigation.
5.0 REQUIRED RESOURCES -
The FY 1986 budget did not include funding for the IIP beyond the 3 FTE assigned to AE0D for the IIS. Thus, the IIP requirements (e.g., travel, training, program support, FTE) constitute additional needs to be accommodated within the appropriated FY 1986 NRC budget.
The information provided below addresses the principal resource needs for the IIT portion of the IIP in FY 1986. These estimates are based, in part, on the resources associated with the Davis-Besse investigation. For planning purposes, three IITs are expected for FY 1986, with each IIT composed of five NRC staff members.
5.1 Travel
- IIP Development Activities (IIS/AE0D staff) $ 4K
- IIT Travel (each team of five persons would 45K spend 2 weeks onsite and would make one 3-day followup visit) 5.2 Training It is not clear yet how this training will be funded; e.g., by MDTS through a separate program support contract. Detailed requirements will be developed and implemented as part of the program-activities.
Conduct of IIT Training Courses $45K 5.3 Program Support Program support for equipment such as cameras, tape recorders and supplies in Headquarters would come from ADM; RM would provide portable PCs and related support. The type and quantity of equipment required on a " stand by" basis will be identified as soon as possible to permit prompt acquisition of items not readily available.
- Provide specialized expertise or analysis $200K to support an IIT (AEOD)
Stenographer contractor (ASLP) 65K Equipment (portable PC, cameras, tape 6K recorders and supplies)
TOTAL $355K
5.4 NRC Personnel (FTE)
The following resources were required for the Davis-Besse IIT. It is
, assumed that three IITs of similar scope will be required in FY 1986.
Davis-Besse IIT FY86 (staff years) (3 IITs)
(staff years)
Team Members 1. 0 3.0 l Management and Supervision 0.1 0.3 Support AEOD'(Adm/ Tech) 0.2 0.6 ADM (Cress / Tech'Ed/Sec) 0.3 0.9 Region (Adm/Sec) 0.1 0.3 1
TOTAL 1. 6 51
- In addition, personnel will be required to prepare, review,'and implement the various activities required to establish and maintain the IIP. The resources include
i FY86 (staff years)
1 Other Offices and Regions >
(e.g., prepare and review the IIP manual chapter, i participate in IIP training) 1. 5 T5 6.0 SCHEDULE 4
ACTIVITIES REQUIRED FOR INITIAL IMPLEMENTATION OF AN IIT IIP Program Plan Target Schedule
, Issue interim program for comment 12/85 Issue final program plan 12/85 NRC Manual Chapter-Issue draft for comment 2/86 Receive comments 3/86 Issue for concurrence 4/86 Issue final 5/86
{ Personnel Rosters 4 Develop a list of candidate team members .
1/86 Receive comments and develop background information 2/86 4
Rosters complete 3/86 i
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Training Plans Hold discussions with FAA, NTSB, DOE, Ontario Hydro, and others to identify relevant training 12/85 Draft training plans 1/86 .,
Schedule training (funds, contracts, locations, consultants) 2/86 Start training 4/86 Initial IIT candidates' training complete 7/86 Administrative Requirements Develop procedure for handling emergency travel 2/86 including authorizations, advances, tickets, vouchers, and use of credit cards Develop motel and site data bank 4/86 Develop memorandum of understanding with ASLBP 3/86 regarding stenographers / transcripts Identify and requisition equipment required by IIT. 3/86 includ'ng tape recorders, cameras, and miscellaneous supplies. Evaluate and justify need for portable PC equipment.
IIT PROCEDURES Prepare draft IIT procedures manual 4/86 Issue IIT procedures manual for comment 5/86 Issue final IIT procedures manual 7/86 STANDARDIZED LANGUAGE FOR EQUIPMENT Draft language 2/86 ELD review 2/86~
Issue for region / headquarters review 3/86 Incorporate comments 4/86 Issue to regions 5/86 LONG-TERM ACTIVITIES NOT REQUIRED FOR INITIAL IIT IMPLEMENTATION Participation by other Organizations Explore possibility of third party participation - 8/86 Agree upon the type and extent of participation and associated procedures 10/86 Subpoena Power / Power to Aaminister Oath Meet with ELD to scope, issue, and assign responsibilities 4/86 Draft resolution of issue complete 7/86 Incorporate into procedures 9/86
J Authority of IIT to Pre-empt Parallel Investigations Identify authority -7/86 Request ELD for legal analysis 9/86 Routine Testing for Drugs and Alcohol ~.
Evaluate need for testing as part of IIP 6/86 ,
Determine status of related activities 7/86 Evaluate various methods for achieving objectives 8/86 Meet / discuss / plan with ELD 8/86 Draft resolution 10/86 Development of Non-Reactor Incident Program Revise existing guidance and develop s?ecialized 3/87 procedures and personnel rosters as necessary UNSOLICITED INFORMATION FROM PLANT PERSONNEL Identify and evaluate methods 4/86 Determine need for confidentiality 5/86 Develop IIT procedure (if needed) 7/86 e
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. o RFFERENCES
- 1. U.S. Nuclear Regulatory Commission, " Incident Investigation Program," ,
SECY-85-208, June 10,.1985.* l
- 2. Memorandum from W. J. Dircks, to C. J. Heltemes, Jr. , NRC,
Subject:
Implementation of a Revised Program for the Investigation of Significant i Operating Events, November 14, 1985.*
- 3. Letter from J. C. Ebersole, ACRS, to N. J. Palladino, NRC,
Subject:
ACRS Comments on the Possibility of an Organization Like the National Transportation Safety Board (NTSB) for Nuclear Safety, April 11, 1984.*
- 4. W. Y. Kato, et al, Brookhaven National Laboratory, "An Independent Safety Organization," U.S. NRC Report NUREG/CR 4152, February 18, 1985.*
- 5. Letter from H. W. Ledis, ACRS, to N. J. Palladino, NRC,
Subject:
ACRS Comments on the Possibility of an Organization Like the National Transportation Safety Board (NTSB) for Nuclear Safety, March 13, 1985.*
- 6. Memorandum from W. J. Dircks to the Commissioners, NRC,
Subject:
Comments on the Brookhaven National Laboratory Study dated February 15, 1985 entitled, "An Independent Safety Organization," March 28, 1985.*
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- 7. Memorandum from S. J. Chilk NRC to W. J. Dircks and J. E. Zerbe, NRC,
Subject:
Staff Requirements--Briefing on Brookhaven Report on Independent Safety Organization, May 21, 1985.*
- 8. Memorandum from S. J. Chilk to W. J. Dircks, NRC,
Subject:
SECY-85-208, Incident Investigation Program, October 16, 1985.*
- 9. Memorandum from C. J. Heltemes, Jr. to H. R. Denton, NRC et al,
Subject:
Lessons from the Davis-Besse Investigation Effort, August 22, 1985.*
- 10. Memorandum from J. M. Taylor to C. J. Heltemes, Jr. , NRC,
Subject:
Lessons from Davic-Besse Investigation Effort, October 21, 1985.*
- 11. Me:aorandum from J. G. Keppler to C. J. Heltemes, Jr. , NRC,
Subject:
Lessons from Davis-Besse Investigation Effort, October 21, 1985.*
- 12. Memorandum from J. G. Davis to C. J. Heltemes, Jr. , NRC,
Subject:
Lessons from Davis-Besse Investigation Effort, September 4,1985.*
- 13. Memorandum from J. B. Martin to C. J. Heltemes, Jr. , NRC,
Subject:
Lessons from Davis-Besse Investigation Effort, September 9, 1985.*
- 14. Memorandum from R. D. Martin to C. J. Heltemes, NRC,
Subject:
Lessons from Davis-Besse Investigation Effort, September 28, 19u5.*
- 15. Memorandum from T. E. Murley to C. J. Heltemes, Jr. , NRC,
Subject:
Lessons from Davis-Besse> Investigation Effort, September 16, 1985.*
- 16. Memorandum from J. N. Grace to C. J. Heltemes, Jr. , NRC,
Subject:
Lessons from Davis-Besse Investigation Effort, October 1, 1985.
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- 17. Memorandum from G. H. Cunningham, III to C. J. Heltemes, Jr. , NRC,
Subject:
Lessons from Davis-Besse Investigation Effort, September 6, 1985.* )
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- 18. Memorandum from H. R. Denton to C. J. Heltemes, Jr. , NRC,
Subject:
Lessons from Davis-Besse Investigation Effort, October 9, 1985.* ^
- 19. Memorandum from R. B. Minogue to C. J. Heltemes, Jr. , NRC,
Subject:
Incident Investigation Program: Lessons from the Davis-Besse Investigation, September 24, 1985.*
- 20. Memorandum from C. E. Rossi to W. J. Dircks, NRC,
Subject:
NRC Davis-Besse Team Comments on Event Fact Finding Methodology, August 20, 1985.*
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"Available in POR for inspection and copying for a fee.
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Appendix 4
Background on the NRC's Incident Investigation Program In 1977, Harold Lewis, a professor at the University of California, Santa '
Barbara, suggested in a letter to Representative Morris Udall, Chairman of the j House Cemittee on Interior and Insular Affairs, the establishment of a Nuclear Safety Board. This suggested organization would be independent of the NRC, patterned after the National Transportation Safety Board (NTSB), and chartered i to review and analyze nuclear accident precursors and to cecommend actions to prevent similar, potentially, more serious events in the future. The NRC Commissioners recommended against an NTSB-type organization. The Advisory Committee on Reactor Safeguards (ACRS) also recommended against a separate Safety. Board.
Following the Three Mile Island accident in 1979, the Kemeny Commission and the NRC Special Inquiry Group made recommendations regarding the evaluation and 4
assessment of operating events at nuclear power plants. As a result of the Kemeny Commission recommendation that the NRC establish a program for the systematic assessment of operating experience, AE0D was established in 1979.
The NRC Special Inquiry Group in 1979 proposed a broad NTSB-type organization '
whose oversight function would include operating experience and investigation i of operating events, and also general oversight of selected licensing and other regulatory functions. This independent organization was also referred to as a ,
Ntclear Safety Board, which is the same title as proposed by Professor Lewis two years earlier, but expanded beyond event investigation.
in IMh e M ti w.w (4refud intp framn that would have established a Nuclear Safety Board. ir di m n M , t!% 'Nouse Committee on Interior and
, Irac y r Affpip radified the bill significantly; for exampla, the authority of l i.b6 enight) hder Mf#ty Wrd ta r*rsee the performance of the NRC and the resolution of vermiM LMety MWu e eliminated. The bill was never introduced for considerettun by the licose of Representatives.
In April 1984, the ACRS recommended in a memorandum'(Ref. 3) to the Commission that AEOD be elevated to the status of a Commission office. In making this l
recomir.endation, ACRS believed there was a benefit or need for an independent review of operating events by an organization reporting directly to the.
Commission.
!- In conjunction with the FY 1985 NRC Appropriations Act, Congress required that
) the NRC conduct a study, to be submitted to Congress within six months,- of the
- i need for and feasibility of an independent organization responsible for conducting investigations of significant safety events including significant operational incidents, at facilities licensed by the Commission. Subsequently, responsibility for the study was assigned to AE00. In August'1984, AEOD contracted with the Brookhaven National laboratory (BNL) to conduct the study, t
In February 1985, BNL issued its report (Ref. 4). BNL concluded that a quasi-independent, statutory Office of Nuclear Safety headed by a Director
- reporting to the Commission should be established. This office would have the
primary responsibility for conducting investigations of significant events at NRC-licensed facilities. BNL further recommended that this new office absorb the current responsibilities of AE0D.
The ACRS provided their comments on the BNL report to the Commission in a
memorandum dated March 13, 1985 (Ref. 5). The ACRS endorsed the formation of -
a new statutory office.
The EDO provided comments on the BNL report to the Commission in a memorandum dated March 28, 1985 (Ref. 6). The ED0 opposed the major BNL conclusion indicating that the implementation of the BNL recommendation would entail major resource commitments and result in staff and program disruptions. However, he agreed that a number of recommendations made by BN'. could improve the existing incident investigation process.
On May 9, 1985, the Commission met with the t<.aff and BNL representatives to receive a briefing on BNL's report. Subsequently, the Commission directed the staff to recommend a proposed program to t'ie Commission that-incorporated needed improvements that were identified in the BNL report (Ref. 7).
The staff proposed the Incident Investigation Program (IIP) in SECY-85-208 (Ref. 1). Coincidently, the Davis-Besse total loss of feedwater event occurred the day before SECY-85-208 was provided to the Commission for approval. The investigation of the Davis-Besse event followed the policies and practices defined in the Commission Paper and thus served as a model for future in-vestigations and for the development of the Incident Investigation Program.
On October 16, 1985, the Commission approved the staff's proposal described in SECY-85-208, to improve the investigation of significant operating events.
Subsequently, the EDO directed the Director of AE0D to develop, administer, and coordinate the IIP (Ref. 2).
An Incident Investigation Staff (IIS) was established as an organizational element within AEOD to respond to the ED0's directive. The IIS is responsible for the further d velopment, coordination, and implementation of the IIP as defined in this plan. In addition, during investigations of significant operational events, the IIS will participate in and support the IITs as appropriate.