ML20148S232
| ML20148S232 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 06/27/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20148S183 | List: |
| References | |
| 50-289-97-04, 50-289-97-4, NUDOCS 9707080139 | |
| Download: ML20148S232 (67) | |
See also: IR 05000289/1997004
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U. S. NUCLEAR REGULATORY COMMISSION
REGION I
Docket No:
50-289
Report No:
50-289/97-04
Licensee:
GPU Nuclear
Facility:
Three Mile Island Nuclear Generating Station
Location:
P.O. Box 480
Middletown, PA 17057
Dates:
May 12-15,1997
Inspectors:
J. Laughlin, Emergency Preparedness Specialist, Region i
J. Lusher, Emergency Preparedness Specialist, Region l
N. McNamara, Emergency Preparedness Specialist, Region i
D. Silk, Sr. Emergency Preparedness Specialist, Region i
W. Maier, Emergency Preparedness Specialist, NRR
S. Klementowicz, Health Physicist, NRR
M. Evans, Sr. Resident inspector, Three Mile Island
R. Bores, Senior Project Manager, Division of Reactor Safety
Approved by:
James T. Wiggins, Director
Division of Reactor Safety
9707000139 970627
ADOCK 05000289
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EXECUTIVE SUMMARY
Three Mile Island
Remedial Emergency Preparedness Exercise Evaluation
Inspection Report 50-289/97-04
This inspection evaluated the licensee's performance during its remedial emergency
preparedness (EP) exercise. The inspectors observed emergency response facility (ERF)
staffing, procedure implementation, effectiveness of mitigation actions, communications,
command and control, emergancy classification, offsite notifications, and protective action
recommendation (PAR) formulation. The inspectors also assessed licensee activity
pertaining to the four exercise weaknesses that were identified during the March 5,1997
full-participation exercise.
Overall exercise performance was good, and much improved over the March 5 exercise.
Event classifications were timely and accurate. Notifications to offsite officials and the
NRC were timely. The PAR was appropriate and transmitted to offsite agencies in a timely
manner. There was very good interaction between the EOF staff and Commonwealth of
PA staff, a noticeable improvement since the March exercise. Remediation of the four
weaknesses from the March exercise was adequately demonstrated during this exercise,
and two of them are closed. However, two of the weaknesses are still being considered -
for enforcement action (not declaring a General Emergency in a timely fashion, and not
considering a PAR outside 10 miles). The weakness (weak dose assessment) and
unresolved item (PAR methodology not conforming to federal guidance) from the 1995
exercise were closed as well.
The licensee's post-exercise critique was also much improved over the one in March,
identified most of the NRC independent findings, and was assessed as good.
Three issues identified during the inspection of the licensee's corrective actions taken for
the March exercise weaknesses, were determined to not be in compliance with NRC
requirements. First, there was no documentation of the continuous on-line assessment or
quick calculation computer codes, nor were there written procedures to aid dose assessors
in performing dose projection calculations. Secondly, the licensee assigned individuals to
its ERO duty roster whose qualifications had lapsed. Lastly, although the EP program
audits identified this ERO qualification issue and other deficiencies, the audit process was
inadequate to correct tho.se deficiencies. These issues are violations of NRC requirements.
Although the TSC staff was able to accurately use the new steam generator leakrate
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calculation tool during this exercise, there was disagreement between ERO members
concerning its use. Additional guidance may be needed for 1) who should use the tool,
and when it should be used, and 2) the limitations of the tool related to damage class
estimates and use in differing scenarios.
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TABLE OF CONTENTS
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EX EC UTIVE S U M M ARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii
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R e p o rt D e t a ils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
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P3
EP Procedures and Documentation
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P3.1
Review of Procedure Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
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P3.2 Documentation of Dose Assessment Computer Codes and Associated
User Manuals
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P4
Staff Knowledge and Performance
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P4.1
Exercise Evaluation
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P4.2 Operator Walkthroughs on the Dynamic Simulator . . . . . . . . . . . . . . . . 9
P4.3 Dose Assessment Team Walkthroughs
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P5
Staf f Training and Qualification in EP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
P5.1
Dose Assessment Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
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P5.2 ' Lapse in ERO Qualifications
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P7
Quality Assurance in EP Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
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P8
Miscellaneous EP Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
P8.1
(Closed) Weakness Observed During the April 12,1995 Full-
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participation Exercise: Weak Ability to Rapidly Assess and Reliably
Predict Potential Offsite Radiological Consequences . . . . . . . . . . . . . . 14
P8.2 (Closed) Unresolved item (URI 50-289/95-05-01): PAR Logic
Methodology Not Conforming With Federal Guidance . . . . . . . . . . . . . 14
P8.3 (Open) eel 50-289/97-02-01: Failure to recognize and classify a GE . . 15
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P8.4 (Closed) IFl 50-289/97-02-02: Inadequate technical analysis by TSC
staff . .. . .... . .. ... ... .. .. .. ....... ...... .. .. ..... ... 16
P8.5 (Closed) IFl 50-289/97-02-03: Incorrect analysis of steam generator
t u be le a k ag e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
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P8.6 (Open) eel 50-289/97-02-04: Failure to assess need for PAR beyond
10-mile EPZ
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P8.7 Updated Final Safety Analysis Report (UFSAR) Review . . . . . . . . . . . . 17
P8.8 in-Office Review of Licensee Procedure Changes . . . . . . . . . . . . . . . . 17
V. M anagement Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
X.1
Exit M e e t i ng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
PARTI AL' LIST OF PERSONS CONTACTED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
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INSPECTION PROCEDURES USED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
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ITEMS OPENED, CLOSED, AND DISCUSSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
LI ST OF AC RO NYM S U SED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
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ATTAC H M E NT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-
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Report Details
IV. Plant Support
P3
EP Procedures and Documentation
P3.1
Review of Procedure Revision
a.
Insoection Scope (92904)
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The inspectors reviewed the licensee's reviser' emergency plan implementing
procedure (EPIP)-COM .44, " Thyroid Blocking," to determine if the appropriate
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changes had been made to satisfy NRC concerns identified during the March,1997
exercise.
b.
Observations, Findinas and Conclusions
During the March 5-7,1997, inspection of the licensee's full-participation exorcise,
the inspector reviewed procedure EP!P-COM .44, " Thyroid Blocking," and found
that it directed the Radiological Assessment Coordinator (RAC) to perform an
- assessment of radiation workers' doses prior to authorizing the administration of
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potassium iodide (KI) for thyroid blocking, but the procedure did not contain any
guidance on how to perform the assessment. The licensee agieed to review the
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procedure and make the appropriate changes. During this exercise inspection, the
licensee provided the revised procedure which included specific guidance for the
RAC to use in determining if Kl should be administrated to workers. The inspectors
considered this guidance to be acceptable. No additional problems were noted.
P3.2 Documentation of Dose Assessment Computer Codes and Associated User Manuals
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a.
Inspection Scone (92904)
The inspectors sought to review documentation of the continuous on-line
assessment (COLA) computer code, RAC computer code, and the quick calculation
computer code. They also reviewed the licensee's Emergency Dose Ca/cu/ation
Manual (EDCM) and various other dose assessment documentation to determine the
adequacy of that documentation for accident assessment.
b.
Observations, Findinas, and Conclusions
The inspector requested the documentation for the COLA computer code, the RAC
computer code, and the quick calculation computer code. No documentat;on was
available for the COLA or quick calculation codes, and the documentation for the
RAC code was minimal. The inspectors concluded that these computer codes
needed thorough verification and validation to ensure that licensee personnel are
knowledgeable on current system operation. Additionally, no user manuals were
available for any of the dose assessment computer codes. The licensee had
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developed some informal guidance for use of the codes by dose assessment staff,
but this guidance had not been incorporated into procedures or a formal training
program. The inspectors also noted there was no reference to the use of these
computer codes in the EPIPs.
The inspector reviewed the EDCM, revision five, dated October 30,1995,and
Temporary Change Notice 1-97-0010 to the EDCM, dated February 26,1997. The
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EDCM provides the basis for the calculations used in the RAC code, but does not
provide any consideration for radiciodine and radioactive particulate depletion under
various reactor accident conditions and for various release pathways. Though the
EDCM is referenced in the licensee's EPIPs, it was not apparent to the inspectors
that the information it contains is utilized for assessment. The inspectors concluded
through table-top walkthrough exercises with dose assessment staff and the
licensee's performance during the remedial exercise that the staff could adequately
use the computer codes for dose assessment calculations. However, the lack of
documentation and user manuals greatly hampered the consistency and quality
control of dose assessment training to ensure sustained good performance.
The licensee's Technical Specifications, Section 6.8.1 states, in part " Written
procedures shall be established, implemented and maintained covering the items
referenced below: ... f. Emergency Plan implementation." The licensee had no
written procedures to aid dose assessors in performing dose projection calculations.
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As mentioned, there was no documentation for the COLA and quick calculation
computer codes. The inspectors concluded that dose assessment personnel were
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dependent on training and informal mechanisms, rather than strutured procedures
and documentation to perform their assessment function. This resulted in a dose
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assessment weakness during the April,1995 exercise and inaccurate assumptions
which led to excessively high dose projection calculations during the March,1997.
exercise. The lack of documentation of the dose assessment computer codes and
procedural guidance for their use is a violation (VIO 50-289/97-04-01).
P4
Staff Knowledge and Performance
P4.1
Exercise Evaluation
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a.
Exercise Evaluation Scoce (82301)
During this inspection, the inspectors observed and evaluated the licensee's
remedial, emergency preparedness exercise, to verify the effectiveness of corrective
actions taken as a result of poor performance in the March 5,1997 full-participation
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exercise, when four exercise weaknesses were identified. The NRC team observed
activities in the emergency control center (ECC) simulator, technical support center
(TSC), operations support center (OSC), and emergency operations facility (EOF).
The inspectors assessed licensee recognition of abnormal plant conditions,
classification of emergency conditions, notification of offsite agencies,
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development of PARS, command and control, communications, and the overall
implementation of the Emergency Plan. In addition, the inspectors attended the
licensee's post-exercise critique to evaluate the licensee's self-assessment of the
exercise.
b.
Emeraency Resnonse Facility (ERF) Observations and Critiaue
b.1
Emeraency Control Center (ECC)
The Emergency Response Organization (ERO) staffed the ECC in a timely manner.
The facility was functional within thirty minutes of the Alert declaration.
The Emergency Director (ED) exhibited very strong command and control of the
ECC staff. He effectively directed the staff to accomplish diverse tasks
concurrently. He delivered clear, accurate briefings to the ECC staff at appropriate
intervals, and effectively consulted with his staff when collegial discussions we.a
needed.
All emergency event classifications were accurate and timely. The General
Emergency (GE) declaration was based on Emergency Action Leve! (EAL) G4.2, i.e.,
" loss of two fission product barriers with a potential loss of the third." The ED
declared the GE, with Emergency Support Director (ESD) concurrence, because the
reactor coolant system and fuel clad barriers were lost, and the containment was
challenged. The inspectors noted that the basis for EAL G4.2 provides some
guidance for determining whether barriers are challenged or breached, but does not
specify guidance for every possible situation. Therefore, the ED exercised -
judgement in determining that the containment barrier was challenged. The
inspectors concluded that the GE declaration was appropriate in this case for the e
existing plant conditions, which were degrading Therefore, the weakness
concerning the failure to recognize and classify a GE from the last exercise was
adequately demonstrated during this exercise. However, it is being considered for
enforcement action (See Section P8.3).
The inspectors reviewed the licensee's proposed Revision 5 to the classification
procedure, which is based on the NUMARC guidance contained in NUMARC/NESP-
007 and endorsed by the NRC in Revision 3 to Regulatory Guide 1.101. This
revision contains an explicit " judgement" EAL for GE conditions that is completely
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separate from the fission product barrier EALs. Therefore, this revision, when
approved by the NRC, will provide a GE-level " judgement" EAL and remove the
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potential arbitrariness of GE declarations based on the challenge to fission product
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barriers.
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Notifications made to offsite authorities and the NRC for the Alert and Site Area
Emergency were timely and accurate.
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The ED and his staff appropriately considered the safety of onsite personnel. When
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the release from the Reactor Building began, the ED consulted with the Radiological
Assessment Coordinator (RAC) concerning emergency dose authorizations for repair
teams, and also evaluated the need for administration of thyroid blocking agent to
those teams.
However, the ED was slow (delayed about one hour) in requesting a reactor coolant
sample after the trip of reactor coolant pump.1 A. This sample would have provided
information on potential fuel damage, as well as aided in quantifying primary-to-
secondary leakage, and any potential offsite doses.
The ECC staff effectively assessed plant conditions and initiated timely and
appropriate corrective actions. For example, the Operations Coordinator (OC) was
proactive in his efforts to reinstate Auxiliary and Fuel Building ventilation after it
was lost. He also provided timely background information to the ED to evaluate a
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discrepancy between radiation monitoring channels in the Reactor Building. The
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Shift Technical Advisor continuously monitored plant temperature and pressure and
reported these parameters' proximity to various thermal limits.
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Throughout the exercise the operating crew effectively dealt with the challenges to
plant safety. The operators implemented the appropriate emergency operating
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procedures in'a timely manner. Procedural adherence was evident. The crew
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employed strong operating practices such as the initialing of procedural step
completion and the use of repeat-backs in communications.
One operating decision was made without explicit procedural direction. During the
latter stages of the exercise, with a reactor coolant system (RCS) leak of greater +
'than 2000 gpm, the operators throttled low pressure injection (LPI) flow to the RCS
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in order to maintain a desired RCS pressure. The licensee's small-break loss of
coolant accident cooldown procedure (in effect at the time) provides no guidance
relative to throttling LPI flow. This decision did not adversely affect plant safety, as
LPI flow adequately compensated for the RCS leakrate. The licensee's Operations
Department acknowledged this procedural weakness and is evaluating the issue
through its " Procedure Problem (s) Identified by. Training" process.
b.2 Dose Assessment in the ECC
Shortly after the Alert declaration, the Group Radiological Controls Supervisor
arrived at the ECC and activated the dose assessment function. He immediately
activated the automated dose assessment computer to obtain an initial dose
assessment and called for additional personnel.
The RAC arrived within 15 minutes of the Alert declaration and, after receiving a
-turnover, took charge of the dose assessment function. The RAC exhibited
excellent command and control of the dose assessment team. -Team members were
assigned positions and directed to review procedures to support dose
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assessment activities. The RAC routinely briefed the team members on plant status
and his communications were clear and direct. The use of repeatbacks was
observed in communications and, in at least one case, prevented the
communication of erroneous information,
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The RAC directed his staff to perform dose projection calculations based on existing
plant conditione using the continuous on-line assessment (COLA) computer code
and to perform "what if" calculations using the manual code. The personnel using
the codes appeared knowledgeable and used the appropriate correction factors
when using the manual code,
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The field monitoring team (FMT) data were provided by onsite and offsite teams.
Communications between the RAC and the FMTs were good. The RAC positioned
the FMTs effectively based on the meteorological data so that they could measure
the radiation levels and obtain air samples. The RAC used the field data in
conjunction with the data from the Reuter-Stokes (R-S) area radiation monitors to
verify the accuracy of the dose projection calculations.
The inspectors observed effective coordination between the RAC and the
Radiological Controls Coordinator (RCC)in the OSC concerning the radiological
safety of radiation survey and repair teams. The RAC discussed the need for
radiation dose extensions with the ED in order to complete repairs of plant
equipment.
Overall, the inspectors noted effective coordination, teamwork, and communication
between dose assessment personnel and the ED concerning radiological conditions.
The RAC demonstrated excellent control of the dose assessment area and direction
of the FMTs. He had frequent interactions with his staff, the ED, and the operating
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crew concerning radiological conditions, both onsite and offsite. He exhibited a
questioning attitude and continually anticipated the next course of action. Dose
assessment team members effectively performed their job functions.
A weakness from the April,1995 exercise concerning the licensee's ability to
rapidly assess and predict potential offsite radiological consequences was reviewed.
During this exercise, the licensee adequately demonstrated its ability to perform
effective dose assessment calculations and make protective action
recommendations. This exercise weakness is closed.
b.3 Technical Sucoort Center (TSC)
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The TSC was staffed and activated in a timely manner. The TSC coordinator
(TSCC) exhibited good command and control throughout the drill. His staff briefings
were generally done at appropriate intervals. TSC priorities were properly identified,
matched ECC priorities, and were appropriately assigned for followup to the TSC
staff. Since the March 5,1997 exercise, a new status board was added to the
TSC, which presented event classification, status of fission product barriers, and
NRC fuel damage class. This information ensured that TSC staff members were
uniformly aware of important information.
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The TSCC and his assistants effectively processed the available data to make
accurate assessments of plant conditions. The TSC staff was aware of plant
conditions shortly after events occurred and in some instances as they occurred.
The addition of a plant performance monitor (PPM) computer in the TSC was a
major enhancement. For example, through monitoring the computer, an engineer
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identified the first RCS leak prior to being informed of the leak by the ECC. On
another occasion, an engineer identified a reduction in LPI flow shortly after it
occurred, and questioned the operators' basis for the reduction in flow. The new
staffing arrangement in the TSC, which provided the TSCC an assistant and
advisor, generally improved the operation of the TSC. However, occasionally the
roles of the coordinator and the assistant overlapped which appeared to cause some
difficulty in the flow of information. The coordinator addressed this problem on
several occasions by conducting briefings with his assistant and advisor.
The TSC staff effectively referenced plant procedures to maintain an understanding
of plant conditions. The EALs were reviewed and discussed with the ECC. The
TSC did not fully understand the basis for the GE declaration and appropriately
questioned the ECC. The TSC staff provided good identification and evaluation of
several "what if" scenarios. For example, they pursued writing a procedure for
starting a reactor coolant pump with no sealinjection flow assuming they could
potentially lose the only operating make up/high pressure injection pump. The TSC
staff appropriately calculated fuel damage class as needed during the drill.
The TSC staff appropriately used the RCS activity versus condenser off-gas monitor
readings, as well as discussions with the RAC, to calculate the primary-to-
secondary leakrate. Although, their calculation did not match the expected result
(they calculated between .1 and .5 gpm versus the actual 3.0 gpm leakrate on the
simulator), it was an appropriate calculation based on the radiation monitor data
available during the exercise.
The TSC staff also demonstrated that they could effectively deal with conflicting
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information within the ERO. For example, while the TSC staff used the new
radiation monitor leakrate methods to calculate primary-to-secondary !eakrate, the
RAC used the new tool to estimate fuel damage class by assuming that the primary-
to-secondary leakrate had not changed. Therefore, the RAC considered the increase
in condenser off-gas reading to be due to increased RCS activity and thus a change
in fuel damage class. It was not clear to the inspector that the new leakrate
method was intended to be used in this manner. As a result, the TSC staff
unnecessarily expended additional resources to evaluate conflicting information on
damage class reported by the RAC early in the drill. The disagreement between the
RAC and the TSC staff conceming the use of the tool for estimating fuel damage
class demonstrated that additional guidance may be needed for: 1) how, who, and
when the tool should be used, and 2) the limitations of the tool related to damage
class estimates and use in differing scenarios (IFl 50-289/97-04-02).
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In conclusion, the overall technical analysis of simulated accident conditions
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provided to the ECC by the TSC staff during the exercise was excellent. Therefore,
the weakness concerning inadequate technical analysis by the TSC staff during the
March 5 exercise is closed (See Section P8.4). Additionally, the TSC staff was able
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to use the new assessment tool to accurately calculate primary-to-secondary
leakage. The weakness related to the incorrect analysis of primary-to-secondary
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leakage is also closed (See Section P8.5).
b.4 Operations Sucoort Center (OSC)
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The OSC was staffed and activated within 15 minutes of the Alert declaration. The
OSC Coordinator exhibited excellent command and control, provided detailed
briefings and effectively utilized the expertise of his managers. Logs and status
boards were well-maintained and in-plant repair teams were effectively tracked.
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Job priorities were established, tracked and adjusted when plant conditions
changed.
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The licensee dispatched 15 in-plant repair teams. The emergency maintenance
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coordinator ensured the teams were thoroughly briefed before dispatch. The
inspector observed one of the maintenance teams and found the team members to
be professional, knowledgeable, and capable of performing their assigned task. The
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inspector observed very good teamwork and excellent discussions among the OSC
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staff for deciding the process for closing the inboard reactor building purge valve.
Two TSC engineers provided their technical expertise, ERO staff thoroughly
evaluated plant diagrams, and a video picture was obtained to view the valve
location.
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The Radiological Controls Coordinator was very good at ensuring radiological
conditions were discussed with the repair team members, alternative routes for
teams were discussed to ensure that doses were maintained as low as reasonably
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achievable, and dose extension approvals were obtained in a timely manner.
Overall, the OSC performance was excellent.
b.5 Emeraency Operations Facility (EOF)
The command and control in the EOF demonstrated by the emergency support
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director (ESD) was very good. The ESD maintained a professional environment by
keeping the noise level to a minimum and instructing his staff to not bring food into
the working area. The ESD held frequent and informative briefings via the public
address system to inform the EOF staff of current conditions. The ESD conducted
effective meetings with the EOF team leaders by eliciting input, discussing
mitigation strategies, and anticipating emergency classification escalation and the
acsociated PAR.
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The EOF staff interfaced well with representatives from the Commonwealth of
Pennsylvania during the exercise. These representatives were included in the
licensee's team leader meetings where their comments and questions were well
received and appropriately addressed by the EOF staff. The staff kept the
Commonwealth representatives apprised of changing plant conditions. The
notification of the GE classification, and the associated PAR, was communicated to
Commonwealth and county officials in a timely manner. Plant and radiological
conditions were reviewed continuously with Commonwealth representatives to
assess the need to extend the PAR out to 10 miles or beyond. Overall, the
interaction between the licensee and offsite officials was very good.
The technical support staff in the EOF promptly and thoroughly assessed plant
conditions. Plant status and conflicting information was continuously verified for
accuracy. The technical support staff maintained contact with and worked closely
with TSC staff in assessing plant status and developing mitigation strategies. The
EOF staff closely tracked all assigned tasks to their completion. Overall, the
technical support function at the EOF was performed very well.
The inspectors attended the post-exercise debrief of players and observers at the .
EOF. The debrief was appropriately self-critical as the comments were balanced
with positive and negative observations.
Overall, the inspectors assessed the licensee's performance at the EOF to be very
good.
b.6 Dose Assessment - EOF
The performance of the Group Leader Radiological and Environmental Controls
(GLR &EC) was good. He was constantly aware of the radiological problems onsite
and offsite. He directed good discussion of the primary-to-secondary leakage issue
with his staff and the TSC staff. He also discussed at length the PAR decision with
the ESD and Commonwealth of PA representatives, and provided key input for the
final decision. The assistant GLR &EC performed several "what if" dose assessment
calculations prior to the release to determine potential offsite consequences,
including ones beyond the 10-mile emergency planning zone (EPZ).
However, the EOF staff did not establish a priority for obtaining a reactor coolant
sample to verify the radiological source term and the amount of primary-to-
secondary leakage. The inspector also noted that if the EOF dose assessment staff
had been limited to the minimum staffing levels prescribed in the emergency plan,
they may not have been able to effectively accomplish all tasks required of them.
Overall, the performance of the EOF dose assessment staff was good.
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b.7 Exercise Conduct
The licensee exhibited appropriate control of the exercise. Drill controllers
maintained minimalinteraction with exercise players and followed the scenario
scope and timeline. The inspectors observed no prompting of the players and all
cues given to the players were appropriate,
b.8 Licensee Exercise Critioue
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Immediately following the exercise, the licensee began its critique process. Players
and controllers assembled in their assigned facilities and conducted a' critique of .
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their exercise performance. The inspectors noted that these facility critiques were
very effective and provided an improved level of self assessment compared to the
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ones following the March 5 exercise.
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The NRC inspection team attended the licensee's formal critique on May 15,1997.
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This critique was much improved over the previous formal critique. The licensee
{
discussed in detail whether the exercise objectives were met. Findings were
-i . characterized clearly for management, identified most NRC findings, and was
' assessed by the team as good.
c.
Overall Exercise Conclusions
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Overall, the licensee's exercise performance was good, and showed much
improvement over the March 5 exercise. The ERFs were staffed in a timely manner.
- All ERF managers exhibited good command and control. The classification of
. simulated accident events were timely and accurate. Notifications to offsite -
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officials and the NRC were timely. The PAR was appropriate and transmitted to ;~
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offsite agencies in a timely manner. The performance of the OSC staff was
excellent and the OSC coordinator demonstrated excellent command and control.
The four weaknesses from the March exercise were adequately demonstrated and
two were closed. However, two of the weaknesses are being considered for
enforcement action. The weakness and unresolved item from the April,1995
exercise were also closed. The licensee's post-exercise critique was much
improved, identified most NRC findings, and was assessed as good.
P4.2 Operator Walkthrouahs on the Dynamic Simulator
a.
Inspection Scooe (92904)
The inspectors observed three senior reactor operators (SROs) classify simulated
accident events during scenarios on the simulator in dynamic mode, to assess the
classification training provided to SROs.
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b.
Observations. Findinas, and Conclusions
All SROs observed (two shift supervisors and one shift foreman) correctly classified
the simulated events and made appropriate classification upgrades, as necessary.
Overall, the inspectors assessed the operators' training and ability to use the EALs
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for event classification as good.
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P4.3 Dose Assessment Team Walkthrouahs
a.
Insoection Scoce (92904)
The inspectors conducted table-top walkthrough exercises with two dose
assessment teams, each consisting of a Radiological Engineering Support Engineer
(RESE), a Radiological Assessment Coordinator (RAC), and a Group Leader-
Radiological and Environmental Controls (GLR &EC), to assess the adequacy of dose
assessment training,
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b.
Observations. Findinos, and Conclusions
Both dose assessment teams observed performed wellin their understanding and
use of the dose assessment computer codes. They were knowledgeable of the
assessment process and understood the limitations / assumptions of the codes. They
were also familiar with the informal guidance recently provided for computer code
use. Inspectors concluded that although the licensee lacked computer code
documentation and user manuals for the codes, the training provided to team
members was adequate for . factive assessment of radioactive releases and their
consequences.
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P5
Staff Training and Qualification in EP
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PS.1
Dose Assessment Trainina
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a.
Inspection Scoce (92904)
The inspector reviewed lesson plans and training examinations for 1995 and
1996, and interviewed training instructors and ERO personnel to determine
the adequacy of the dose assessment training,
b.
Observations, Findinos and Conclusions
The licensee provided extensive dose assessment training after the March,
1997 exercise. The inspector reviewed the lesson plans and procedures and
found them to include both classroom instruction and hands-on training.
Some of the topics discussed included review of the existing COLA screens,
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situational analysis, and the PAR logic revision. The inspector reviewed the
examinations and determined the exams given to the EOF dose assessment team to
be somewhat abbreviated and nontechnical. The exams for the ECC dose
assessment teams were more challenging with some technical questions, and the
average grade was 99 percent.
The inspector discussed the dose assessment training with dose assessment
team members and they indicated that training was adequate and had
improved over the past two years. The remedial training that was provided
after the March,1997 exercise was excellent because it provided
discussions of the methodology for assessing releases and their
consequences when using the COLA or manual dose assessment models.
During the interviews, the dose assessment teams referred to a " dose
assessment committee." This was not a formal committee but it was
established to look into the maintenance of the dose assessment models and
respond to any dose assessment concerns. Dose assessment team members
acknowledged that the committee was an excellent idea, however, it did not
meet on a regular basis, and there were no formal procedures that described
the activities of the committee, such as handling suggestions for
improvements. The inspector assessed the committee as an excellent
initiative, which could assist the licensee in maintaining the dose assessment
program, and address identified concerns and problems.
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P5.2 Laose in ERO Qualifications
a.
Insoection Scope (92904)
The inspector reviewed the 1995 and 1996 quality assurance audits to assess an
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issue concerrdng the lapse in qualifications of some ERO personnel.
b.
Observations. Findinas and Conclusions
While reviewing the quality assurance audits of 1995 and 1996, the
inspector noted that the licensee identified several instances in which ERO
personnel had allowed their respirator training or whole body count to expire.
The EP staff was aware of this recurring problem and has been working to
establish effective tracking systems. As a result of improved tracking of
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expired qualifications, the number of unqualified individuals has decreased in
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the past three years. Although the tracking systems have improved the
process, the licensee plans to present this matter to site plant management
to gain support and endorsement in ensuring that all ERO personnel are
aware of their responsibilities to maintain their qualifications current.
The inspector determined that the licensee did not follow procedure TEP-
ADM-1300.02, " Emergency Pieparedn9ss Training," Section 4.0, Exhibit 1,
which states in part, "On-Shift Emergency Organization, initial Response
Emergency Organization and Emergency Support Organization must
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satisfactorily complete and maintain EP training program requirements for the
position assigned and must satisfactorily maintain respirator qualifications
and General Employee Radiation Worker Training (Category ll) and must be
active in the dosimetry system." Therefore, the inspector concluded that the
licensee repeatedly, over a three year period, had individuals on the ERO
duty roster that were not qualified. This is a violation (VIO 50-289/97-04-
03).
P7
Quality Assurance in EP Activities
a.
Inspection Scoce (92904)
The inspector reviewed Nuclear Safety Assessment (NSA) EP program audit
reports, quality deficiency reports (ODRs), procedures and other
documentation tc assess the adequacy of the EP audits conducted in 1995
and 1996. The inspector also interviewed the 1996 audit team leader, EP
Manager, and EP staff members.
b.
Observations and :indinas
The NSA Dcortment conducts an annual EP program quality assurance
audit. The 19S5 and 1996 audits were conducted by the same two NSA
staff members wiih no EP technical experience. The audits consisted of an
audit plan and checkUst and were conducted over a three-month period. The
inspector reviewed the 1995 and 1996 audit reports and identified several
areas of concern.
The licensee's Emergency Plan, Section 8.2.1, required essential personnel
to reverify their assigned EP training every 12 to 15 months to maintain
current qualifications. A ODR, number 942005 was issued to the EP
Department as a result of a 1994 EP program audit for a number of
individuals on the ERO duty roster with incomplete training. As a result of
this deficiency, the EP staff implemented a computerized EP qualification
tracking system in late 1994 to monitor training qualification records.
However, during the 1995 EP program audit, nine individuals were identified
with expired qualifications, four of which were on duty. The audit report
indicated that an additional computarized tracking system was being
implemented and scheduled for completion by September 1,1995 and ODR
942005 remained open.
In February 1996, the QDR was closed by memorandum from the EP Manager to
the Director, Radiation Health and Safety, stating that the EP Department continued
to monitor EP qualifications and a new tracking system was in place. However,
during the 1996 EP program audit, an EP staff member stated that over a six-month
period, ten ERO personnel had their qualifications lapse, three of which were on
duty. The report stated, "since the actual error rate for expirod qualifications while
on duty is very low it will be considered a minor deficiency."
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The NSA Audit Program Procedure 1110-ADM-7218.10 defines a minor
deficiency as one not being programmatic, not generic, does not compromise
quality, is not potentially reportable, and/or corrective action would not be
extensive. The independent safety reviewer who evaluated the 1996 audit
stated that "no significant safety conditions were identified, all findings were
properly characterized as QDRs or minor deficiencies and no undetected
trends were identified by this review." The inspector disagreed with the
decision to downgrade the ODR to a minor deficiency and the determination
that no trends were identified since ERO qualification problems had been
identified in the past three audits (one individual's qualifications had lapsed
as recently as March,1997). The audit team leader stated that the EP staff
identified the individuals and removed them from the ERO upon discovery.
Since the EP staff was addressing the ERO qualification problem, NSA
decided that a QDR was not necessary. Also, the auditor stated that NSA
did not do an independent assessment during the 1996 audit to verify that all
members of the ERO were qualified at that time.
Discussions with the EP Manager about this matter indicated that the
problem was not only poor tracking systems but also the lack of
management expectations regarding ERO personnel maintaining their
qualifications current, and the consequences for not doing so.
While reviewing the audit reports, the inspector noted other " minor deficiencies"
that were similar in nature in the 1995 and 1996 reports. For example, copies of
EPIPs, the Emergency Plan, and operating procedures and drawings located in
various ERFs were found to be out of date.
In 1996 it was identified that the equipment kits were insufficient and kit
inventories were not being prt arly conducted. Since these issues were
corrected during the audit, the ucensee included them as findings, but did
not assess them as deficiencies. The NSA did not trend these similar
findings and therefore had no historical reference of the EP Department's
performance in this area for identifying recurring issues.
In 1995 it was identified that Lancaster County officials were concerned
about the handling of false siren soundings. The EP staff informed the
auditors that only a few sirens had been inadvertently activated and a
system upgrade was expensive. The EP staff committed to evaluate the
siren system. The 1996 audit stated "there is still a problem with false siren
soundings" and that EP is getting contract bids for installation of a system to
identify faulty sirens and give feedback directly to the counties. Although
this was a repeat item, it was not made a deficiency in the 1996 audit
report. The OA team leader stated that since the EP staff had been
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reviewing this concern for the past two years, and was in the process of making
additional corrective action decisions, the issue did not warrant a deficiency. The
licensee appeared to characterize the repeat audit finding as insignificant due to the
EP staffs' commitment to continue to review the issue. The NSA was
nonconservative in its characterization of findings as conditions adverse to quality,
c.
Conclusions
The inspector determined that the audits covered many areas of review but that
they appeared to be narrowly focused on compliance rather than substance. The
short-term corrective actions taken by the EP staff that were identified during the
audit were considered acceptable even though an in-depth review for determining
the adequacy of the corrective actions was not performed. Characterization of
audit findings appeared to be negotiated with the EP staff and minor deficiencies
were not trended for determination of recurrence. Overall, the inspector assessed
the NSA audit of the EP program to be perfunctory.
The licensee's Technical Specifications, Section 6.5.3.1, states, in part, " audits
shall be performed in accordance with the TMI-1 Operational Quality Assurance
Plan." The Operational Quality Assurance Plan requires that the audit system
provide for corrective action systems and management reviews for timely correction
of identified deficiencies and prevention of recurrent nonconformances. The
licensee did not provide effective prevention of recurring deficiencies nor review
corrective actions for deficiencies to determine their adequacy. This is a violation
(VIO 50-289/97-04-04).
P8
Miscellaneous EP lssues
P8.1
(Closed) Weakness Observed Durina the April 12.1995 Full-carticioation Exercise:
Weak Ability to Rapidiv Assess and Reliably Predict Potential Offsite Radioloaical
Censeauences
The inspection team reviewed this item during this exercise. The licensee
adequately demonstrated its ability to perform effective dose assessment
calculations and make protective action recommendations. This exercise weakness
is closed.
P8.2 (Closed) Unresolved item (URI 50-289/95-05-01): PAR Loaic Methodoloav Not
Conformina With Federal Guidance
The NRC inspection team for Inspection 95-05 concluded that the licensee's PAR
logic diagram methodology did not appear to conform with Federal guidance, in that
it relied on evacuation time estimates and release duration, without consideration of
radiation doses that could be received.
The team reviewed this issue during this inspection. The licensee had revised its
PAR logic diagram in a recent change to the EPIPs. The inspectors reviewed the
revised PAR logic diagram and determined that it satisfactorily follows NRC
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guidance. While the NRC's guidance follows a sector approach, evacuating the EPZ
out to a two mile radius and five miles downwind (the " keyhole" concept), the
licensee's default PAR guidance relies on an evacuation out to a five mile radius.
The licensee chose this approach because topographical characteristics of the plant
caused frequent wind shifts, and to more closely coincide with the PAR
methodology used by offsite officials which prescribes protective actions uniformly
for all sectors. The inspectors concluded that this deviation from NRC guidance
was acceptable.
-The inspectors noted one other way in which the licensee's new PAR logic deviates
from NRC guidance. The licensee's PAR logic diagram recommends the default PAR
for all GE classifications, regardless of core damage severity, except when security
events or known release duration justify otherwise. The NRC guidance recommends
the keyhole evacuation only for severe core accidents. However, a review of the
licensee's EALs revealed that, except for the security events already considered, all
the GE conditions considered in the current scheme would be severe core accidents.
Therefore, the licensee's new PAR logic diagram conforms to NRC guidance, and
the previously: identified unresolved item is closed.
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.P8.3 LQoen) eel 50-289/97-02-01: Failure to recoanize and classifv a GE
]
During the previous exercise, the ERO failed to recognize a condition .in which all
three fission product barriers were breached as one that required a GE declaration.
During this remedial exercise, the ERO accurately recognized the conditions that
constituted each level of emergency classification and declared the appropriate.
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~ emergency classification in each case. The satisfactory performance of the GE w
classification adequately addressed this item from a performance standpoint.
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The inspectors also reviewed the licensee's short-term programmatic corrective
actions taken to respond to the weakness, which included EAL training for ERO
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staff for classification of emergency events and coaching drille held at the various
ERFs to discuss expectations for the principal decision-makers, as well as their
soliciting input from supporting staff members. The inspectors verified that these
short-term corrective actions had been completed.
The inspectors interviewed five ERO members who'had attended the EAL remedial
training. The inspectors noted varying degrees of retention of the information
covered in the training, but concluded that the training was generally effective.
Additionally, the licensee's performaace during the remedial exercise demonstrated
the adequacy of the remedial training, and the licensee incorporated the concepts
covered in the remedial EAL training into the EP continuing training program.
The inspectors concluded that the corrective actions taken for the above weakness
were effective and that the GE classification was adequately demonstrated during
this exercise. However, it is still under consideration for enforcement action.
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P8.4 LQksed) IFl 50-289/97-02-02: Inadcauate technical analysis by TSC staff
The technical analysis of simulated accident conditions provided to the ECC by the
TSC staff during the March 5,1997 drill was inadequate, and was assessed as an
exercise weakness.
To address this weakness, the licensee made significant staffing, roles, and
expectation changes in the TSC. The staffing changes included the addition of two
individuals to directly support the TSC coordinator. For each duty section, one of
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these individuals, the TSC Advisor, was a former STA in the control room. In
addition, the licensee provided additional training to the TSC staff regarding RCS
and primary-to-secondary leakrate calculations, the role of the TSC, expected
resource allocation, control of activities in the TSC, and communications.
Based on the changes made to TSC staffing, the training provided, the leakrate
calculation enhancements and the excellent TSC performance in this exercise, the
previous weakness related to the adequacy of technical analysis of simulated
accident conditions provided to the ECC by the TSC staff is closed.
P8.5 (Closed) IFl 50-289/97-02-03: Incorrect analysis of steam aenerator tube leakaae-
During the March 5,1997 exercise, the analysis of primary-to-secondary leakage by
the ERO was incorrect and assessed as an exercise weakness.
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As a result, the licensee provided guidance and developed new methods to analyze
primary-to-secondary leakage. One of the new methods estimates the leakage
based upon condenser off-gas monitor readings'and RCS activity. The results are -
only as accurate as the estimate of the RCS activity and only when the entire
release is going through the condenser. Based on the estimate of RCS activity and
condenser off-gas readings, off-gas flowrate and a factor from a series of graphs is
used to estimate primary-to-secondary leakage. The licensee provided training on
ihe guidance and new methods for determining leakrates to members of the TSC
and other emergency response staff. The inspector attended the training on May 7,
1997 and found it to be very good and informative.
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Based on the new leakrate determination methods and guidance, the training
provided to the ERO on these tools, and the performance of the TSC staff dunng
this exercise to use the tools in accurately calculating primary-to-secondary leakage,
this weakness is closed.
P8.6 (Open) eel 50-289/97-02-04: Failure to assess need for PAR bevond 10-mile EPZ
During the March 5,1997 exercise, the EOF staff did not assess and discuss with
offsite officials the need for PARS for residents outside the 10-mile EPZ when dose
projections appeared to indicate that the Environmental Protection Agency
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protective action guidelines (PAGs) would be exceeded.
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The inspectors reviewed EPIP-TMl .27, " Emergency Operations Facility." This
procedure requires the GLR &EC to periodically brief Commonwealth representatives
on the current radiological and environmental conditions. The procedure was
revised to require the GLR &EC to immediately notify the ESD if dose assessment
calculations indicated that EPA PAGs would be exceeded anywhere offsite,
inclu ! g outside the 10-mile EPZ. The procedure included a note that clarified that
dose projections for areas from a 10 to 30 mile radius can be performed using a
computer code on the Emergency Information Network. The procedure provided
guidance on protective actions to be taken outside the 10-mile EPZ. The GLR &EC
must notify the.PA Bureau of Radiation Protection of any problems with the dose
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assessment calculations.
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in addition to the guidance contained in the procedure, an e-mail memorandum was
issued on March 12,1997, from Mr.'J. Grisewood to members of the ERO
concerning the importance of thorough communications with Commonwealth
representatives regarding plant conditions during an emergency. Coaching sessions
- were conducted with ERO members on March 27 and April 3,1997 to emphasize
this new guidance.
During this exercise,.the inspectors observed that ERO personnel communicated.
well with Commonwealth personnel on plant and radiological conditions. In
particular, there was good discussion on PAR formulation both within the 10-mile
EPZ and beyond (though a PAR was not necessary beyond the 10-mile EPZ for the
existing radiological conditions). Based on the licensee's improved guidance and
performance during this exercise, this item was adequately demonstrated.
However, it is still under consideration for enforcement action.-
'P8.7
Updated Final Safety Analysis Report (UFSAR) Review
A recent discovery of a licensee operating its facility in a manner contrary to the
UFSAR description highlighted the need for a special focused review that compares
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plant practices, procedures, and/or parameters to the UFSAR or the emergency
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plan'. During this exercise, the inspectors observed the licensee's compliance with
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the emergency plan regarding ERO structure, facility activation and usage, and
classification of simulated events. No discrepancies were noted,
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P8.8 in-Office Review of Licensee Procedure Chanoes
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An in-office review of revisions to the emergency plan and its implementing
procedures submitted by the licensee was completed. A list of the specific
revisions reviewed are included in Attachment 1 to this report. Based on the
licensee's determination that the changes do wt decrease the overall effectiveness
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of the_ emergency plan, and that it continues to mdet the standards of 10 CFR 50.47(b) and the requirements of Appendix E to Part 50, NRC approval is not
required for those changes. Implementation of those changes will be subject to
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inspection in the future.
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V. Manaaement Meetinas
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'The NRC convened a meeting with GPU Nuclear management personnel in the Region 1
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office on April 30,1997, to discuss the licensee's root cause evaluation of the March 5
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exercise weaknesses. Mr. E. Frederick summarized the root cause evaluation findings and
- Mr. A. Rone summarized the licensee's short term and long term corrective actions, as well
as the senior management evaluation of the root cause evaluation findings (Enclosure 2).
Of particular note were the conclusions that management oversight and involvement in EP
- was not sufficient, and that management expectations for support of the EP program must
be clearly defined, communicated, and continuously reinforced.
X.1
Exit Meeting
The inspector presented the inspection results to members of licensee management at the
conclusion of the inspection on May 15,1997. The licensee was informed of the
following:
There were no exercise weaknesses identified and performance was much improved
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over the March exercise performance.
The weakness identified during the April,1995 exercise concerning weak ability to
assess.and predict offsite radiological consequences was adequately demonstrated
and is closed.
The unresolved item identified during the April,1995 exercise concerning the PAR
logic methodology not conforming to Federal guidance, was reviewed and the
licensee's changes were satisfactory. Therefore, this item is closed.
"
The four weaknesses identified during the March,1997 exercise were adequately
demonstrated. However,-two were closed (inadequate technical analysis by TSC
staff and incorrect analysis of steam generator tube leekage) and two will remain
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open pending possible enforcement action (failure to recognize and classify a GE,
and failure to assess the need for a PAR beyond the 10-mile EPZ).
The exercise critique was much improved over the March exercise critique,
. identified most NRC items, and was assessed as good.
The inspection team identified an EP audit inadequacy in that an ERO qualification
issue was identified in multiple audits, and not corrected. This item was
unresolved.
The licensee acknowledged the inspection findings.
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A formal exit mereting was conducted on May 28,1997, at the Three Mile Island Training
Center, which was open for public observation. The NRC inspection team leader presented
the inspection findings to Mr. J. Langenbach and other members of the GPU Nuclear staff.
The licensee was informed that:
The four weaknesses identified during the March,1997 exercise were adequately
demonstrated from a performance standpoint. However, two of those weaknesses
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were being considered for enforcement action (failure to recognize and classify a
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GE, and failure to assess the need for a PAR beyond the 10-mile EPZ).
The issue concerning the EP audit inadequacy which was previously unresolved,
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was, after further review, assessed as a violation.
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The issue concerning the lapse in ERO qualifications was ongoing since 1994, and
is a violation.
The issue concerning inadequate documentation of dose assessment computer
codes and user manuals for those codes were impcrtant problems, and is
unresolved.
The licensee acknowledged these findings.
Mr. J. Grisewood, the Three Mile Island EP Manager, presented a summary of the
licensee's actions to close out Confirmatory Action Letter 1-97-011, dated March 12,
1997 (Enclosure 3). The licensee stated that it had also provided this information to the
NRC in writing.
The licensee was subsequently notified by telephone on June 18,1997, that the issue
concerning inadequate documentation of dose assessment computer codes is a violation.
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PARTIAL LIST OF PERSONS CONTACTED
Licensee
N. Brown, Lead Emergency Planner
D. Ethridge, Acting Director, Radiological Controls / Occupational Safety
R. Finicle, Corporate Emergency Planner
E. Frederick, NSA/ Human Performance
R. Goodrich, Site Security Manager
J. Grisewood, Emergency Preparedness Manager
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R. Hess, Manager, Training
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L. Karinch, GPU Nuclear Spokesperson
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A. Knoche, Senior Emergency Planner
J. Langenbach, Vice President and Director, TMI
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A. Miller, Regulatory Affairs
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J. Moore, Nuclear Safety Compliance Committee
W. Ressler, Manager, Environmental Affairs
M. Ross, Director, Operations and Maintv.ance
G. Skillman. Director, Configuration Control
M. Slobodien, Director, Radiological Health and Safety
C. Smythe, Manager, Nuclear Safety Assessment
J. Wetmore, Manager, Regulatory Affairs
J. Whitehead, Senior Emergency Planner
W. Wilkerson, Manager, System Engineering
Commonwealth of Pennsvivania
R. Janati, Bureau of Radiation Protection
S. Maingi, Nuclear Engineer, Bureau of Radiation Protection
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J. Rives, Pennsylvania Emergency Management Agency
Federal Emeraency Manaaement Aaencv
A. Henryson, Region lli
NRC
P. Eselgroth, Chief, Division of Reactor Projects Branch 7
S. Hansell, Resident inspector, TMI
M. Modes, Chief, Emergency Preparedness and Safeguards Branch
J. Wiggins, Director, Division of Reactor Safety
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INSPECTION PROCEDURES USED
82301:
Evaluation of Exercises for Power Reactors
82302:
Review of Exercise Objectives and Scenarios for Power Reactors
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92904:
Followup - Plant Support
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ITEMS OPENED, CLOSED, AND DISCUSSED
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Ooened
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50-289/97-04-01
Lack of computer code documentation and procedures for dose
assessment
50-289/97-04-02
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Additional guidance necessary for steam generator leakrate
calculation tool
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50-289/97-04-03
Personnel on ERO duty roster who were not qualified
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50-289/97-04-04
EP audit program inadequate to correct deficiencies
Closed
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50-289/95-05-01
PAR logic methodology not conforming with federal guidance
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No number
Weakness
inadequate off-site dose assessment and projection
50-289/97-02-02
IFl
inadequate technical analysis by TSC staff -
50-289/97-02-03
IFl
incorrect analysis of steam generator tube leakage
piscussed
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50-289/97-02-01
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failure to recognize and classify a GE
50-289/97-02-04
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failure to assess need for PAR beyond 10-mile EPZ
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LIST OF ACRONYMS USED
CFR
Code of Federal Regulations
Emergency Action Level
Emergency Control Center
Emergency Director
EDCM
Emergency Dose Calculation Manual
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Escalated Enforcement item
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Emergency Maintenance Coordinator
Emergency Plan Implementing Procedure
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Emergency Planning Zone
Emergency Response Facility
Emergency Response Organization
Emergency Support Director
FMT
Field Monitoring Team
General Emergency
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GLR &EC
Group Leader Radiological and Environmental Controls
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GPM
Gallons Per Minute
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inspector Follow-up item
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Potassium lodide
Low Pressure injection
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NRC
Nuclear Regulatory Commission
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Nuclear Management and Resources Council
OC
Operations Coordinator
Operations Support Center
Protective Action Guideline
Protective Action Recommendation
Public Document Room
Plant Performance Monitor
Quality Assurance
Quality Deficiency Report
RAC
Radiological Assessment Coordinator
Radiological Controls Coordinator
RESE
Radiological Engineering Support Engineer
R-S
Reuter-Stokes
Site Area Emergency
Senior Reactor Operator
Shift Supervisor
TMl
Three Mile Island
TSCC
TSC Coordinator
Updated Final Safety Analysis Report
Unresolved item
Violation
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ATTACHMENT 1
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Emergency Response Procedures Reviewed
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Document
Document Title
Revision (s)
5
EPIP-TMI .02
Emergency Direction
10.
EPIP-TMI .03
Ernergency Notifications and Call Outs
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EPlP-TMI .06
Aoditional Assistance and Notification
23,24
EPIP-TMI .27
Er.)ergency Operations Facility
3,10
EPIP-COM .44
Thyroid Blocking
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EPlo-COM .45
Classified Emergency Termination / Recovery
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ENCLOSURE 2
TMI-1
ROOT CAUSE UPDATE
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PROGRESS REPORT
GPU NUCLEAR
APRIL 30,1997
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Agenda
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Background
A. H. Rone
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Short Term Corrective Actions
A. H. Rone
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HPIP Root Cause Evaluation
E. R. Frederick
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Senior Management Evaluation
A. H. Rone
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and Long Term Corrective Actions
Conclusions
A. H. Rone
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Background
Biennial, full participation, graded emergency
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preparedness exercise conducted March 5,1997
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Scenario Summary
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- Exercise started with plant running followed by major
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leak in reactor coolant system resulting in declaration of
S AE. This was accomplished successfully.
- Plant shut-down was followed by damage to fuel clad.
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Damage class was correctly recognized
- Calculation in TSC indicated primary to secondary leak
> 50 gpm. This met EAL for declaration of GE.
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- Calculation done in TSC was incorrect. Drill controller
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halted GE declaration to maintain exercise time line
commitments for offsite participants
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- Decay. Heat line rupture bypassed the containment
building, thus breaching the third fission product barrier.
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This should have resulted in declaration of GE. ERO
did not recognize GE condition, resulting in Drill
Controller prompting to maintain exercise time line
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commitments to offsite agencies.
- Manual offsite dose calculation resulted in estimate of
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60 rem dose at EPZ boundary. Discussions of need for
expanding PAR beyond 10 mile EPZ was limited at
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Exercise Results
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- ERO failed to recognize and declare GE when
conditions warranted
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- ERO staffincorrectly evaluated steam generator tube
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leakage
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- Technical analysis of simulated-accident conditions was
inadequate in TSC
- The EOF staff did not adequately assess need for PAR
beyond the 10 mile EPZ
CAL of March 12 confirmed GPUN commitments to
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remediate drill weaknesses and perform a root cause
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evaluation (RCE)
- Initiate imme~diate corrective actions to address
weaknesses noted above
- Perform a root cause analysis by April 15 covering
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weaknesses along with ERO training, scenario
development, simulator problems, controller activities,
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exercise critique process, and changes in EP and ERO
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- Conduct a remedial exercise by May 15,1997
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The purpose of this meeting is to advise you of the
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- Immediate corrective actions and their results
- Results of the Root Cause Analysis
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- Future plans
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Short Term Corrective Actions
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Root Cause Evaluation (completed April 15,1997)
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TSC capability upgraded
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- Additional computers added
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- Tech Support Coordinators / Assistant position added
- Expectations document issued on support to ECC and
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coordination with EOF
- TSC Engineer assigned as " big picture" advisor
(previous STA or SRO or equivalent qualification)
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ERO Training
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- Diagnosis of conditions and timely declaration
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of emergency conditions [ED, ESD, ED
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Assistant, ESD Assistant, RAC, Group Leader
R&EC]
- Use and limitations of analytical tools (on-
going)
- Diagnosis and analysis of primary to secondary
leakage in steam generators
- Intra-facility communications
- Methodology and need for analyzing population
doses beyond 10 mile EPZ and making oflong
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range protective action recommendations
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Short Term Corrective Actions
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Table top training for EOF, ECC, and TSC
Communicate expectations for ESD and facility
leaders
Procedure upgraded for better quantifcation of
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primary to secondary leakage in steam generators
and RCS leak rates
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Multi-disciplined team used to prepare and
validate remedial exercise scenario
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Short Term Corrective Actions
Enhance exercise critique process by providmg
observers with objective evaluation criteria to
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use in assessing performance
Meeting with Commonwealth of Pennsylvania
and GPUN to review and clarify GPUN/ state
interface expectations, press releases at GE,
PARS beyond 10-miles completed on April 25,
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Mini drill scheduled for May 8,1997
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Management Review of Root Cause Evaluation
conducted April 25,1997
Remedial Exercise scheduled for May 13,1997
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Root Cause Evaluation
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March 5,1997 Emergency Plan Exercise
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E.-R. Frederick
HPES Coordinator, T WI
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HPIP Root Cause Evaluation
Team
E. R. Frederick, Root Cause Analyst (NSA) and Team Leader
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T. Blount, Manager Emergency Preparedness, Oyster Creek NGS
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R. Finicle, Corporate Emergency Planner
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D. Wilt, Instructor IV, Operator Training Department
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C. Husted, Simulator Analyst, TMI Training Department
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R. Rolph, Radiological Engineer, Radiological Health and Safety
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E. Showalter, Engineer Sr., System Engineering Department
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Dann Smith, HPE Coordinator (NSA), Oyster Creek NGS
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Don Smith, Senior Reactor Operator, PDMS Manager
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Weakness No.1: ERO Failed to Recognize a General
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Emergency when Warranted by Plant Conditions
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HPIP Root Cause
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- Training content did not specifically address
job performance standards
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Corrective Actions
- Train on methods for determining fission
product barrier status
- Develop expectations and priorities for ED and
ESD to evaluate Emergency Action Levels
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- Provide more detail in ECC EPIP
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procedure change deferred - NUMARC EALs will
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- Develop expectations for ERF Leaders to solicit
input from ERO members
- Meet with Pennsylvania BRP
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Weakness No. 2: ERO incorrectly evaluated OTSG Tube
Leakage
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HPIP Root Cause
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- Training content did not specifically address
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job performance standards
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- Corrective Actions
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- hands-on training on TSC PC-based leak rate
program addressing limitations with voided
- Provide information on limitations to selected
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Weakness No. 3: Technical Analysis Provided to ERO by
TSC was Inadequate
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HPIP Root Cause
- Training content did not specifically address
job performance standards
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Corrective Actions
- Ensure ERF drills and additional training
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include the following:
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role of TSC in emergency plan
expected resource allocations and control of
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activities in the TSC
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communication techniques
TSC activation and table top exercises
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Weakness No. 4: EOF did not assess the need for PARS
outside the 10 mile EPZ
HPIP Root Cause
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- Policy guidance / management expectations not well
defined or understood
Corrective Actions
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- Ensure procedures direct cross-check ofin-plant survey
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data, offsite data, COLA input, and RAC Code inputs
- Incorporate into RAC and Group Leader R&EC
expectations and procedures for the need for PARS
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outside 10 mile EPZ
- Establish requirements for and tools to evaluate
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performance of dose assessment before using data for
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Scenario Development:
Insufficient input from Rad Con,
Engineering, and Operations to Prevent Deviation from
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Time Line
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HPIP Root Cause
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- Insufficient manpower to support identified goal /
objective
Corrective Actions
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- Use multi-disciplined team to develop / validate
scenario. Validate using sufficient resources to
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effectively represent ERO. Protect confidentiality
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- Develop method to understand how changes may
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disrupt key factors. Ensure all changes undergo
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adequate review and re-evaluation
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Simulator Problems and Usage Issues: Insufficient
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attention given to warnings on avoidable problems.
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Driving Simulator beyond its capabilities. Use of
uncontrolled software.
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HPIP Root Cause
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- Component not operated within its design parameters
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Corrective Actions
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- place auto offsite dose projection system within
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configuration control
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- move COLA assessment computer system to secure
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area
- do not use real time meteorological data for drills and
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exercises
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- control simulation to minimize negative training
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DrillController Activities: Controller activities can be
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overwhelming when drill takes direction not predicted.
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-Meeting the time line is very important.
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HPIP Root Cause
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- Too many concurrent tasks assigned to worker
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Corrective Actions
- reduce intervention required to meet scenario
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- provide properly validated scenario that minimizes
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controller activities and has backup information so
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controllers can respond during system malfunctions
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Critique Process was Unsatisfactory: Critique failed to
identify CAL items 3 and 4
HPIP Root Cause
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- Problem identification methods didn't identify
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need for change
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Corrective Actions
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- develop and implement a formal drill critique
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process
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Changes in Emergency Preparedness Staffing: Corporate
EP Manager position eliminated, EP Manager recently
replaced, Planning staff reduced
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HPIP Conclusions
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- no measurable effect on outcome
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- none
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Changes in ERO Staffing: Role reversal of ED and Ops
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Coordinator, GL R&EC, EAC, RESE, TSR, OSCC filled
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by personnel not in previous exercises
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HPIP Conclusions
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- ED /OC role reversal may have had slightly
negative effect
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- other positions: no noticeable effect
- Corrective Action
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- Do not deviate from established ~ duty roster
assignments for graded exercises
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Effectiveness of Past Corrective Actions: Repeat items
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not captured in trend. Critique process did not identify
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some weaknesses
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HPIP Root Cause
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- Corrective action for previously identified
problem or previous event was not adequate to
prevent recurrence
- Corrective Actions
- Utilize improved Critique Process m
conjunction with CAP system. This will
employ root cause evaluation and corrective
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action development and tracking
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Management Evaluation Team
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A.H. Rone, VP: Nuclear Safety and Technical Support (Chair)
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M. B. Roche, VP. Oyster Creek
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Gregory Kane, Independent General Office Review Board
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Member
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J. Curry, Acting Director Nuclear Safety Assessment
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E.R. Frederick, HPES Coordinator, TMI
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M.J. Slobodien, Director Radiological Health and Safety
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Management Review Team
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Conclusions
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The performance demonstrated by some members of
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the Emergency Response Organization was weak.
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The emergency preparedness process for developing,
validating, controlling, and critiquing the exercise
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scenarios and ERO performance requires a more
systematic and rigorous approach.
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Management expectations for support of the
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Emergency Preparedness program to achieve excellent
performance must be clearly defined, clearly
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communicated, and continuously reinforced as
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- Inadequate resources were applied to scenario
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development and validation. Management failed to
detect this.
- Changes in ERO staffing and the reduction in
experience level in the Emergency Preparedness
organization may have contributed to some performance
weaknesses. Management oversight and involvement
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was not sufficient
- Management did not take adequate actions to ensure
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completion of and continued attention to previously
identified corrective action needs
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Long Term Corrective Actions
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Reinforce management expectations for Emergency
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Preparedness program support e.g.
- Number of resources devoted to EP program
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- Qualifications of personnel assigned to the ERO
- Direct management involvement in evaluations of the
EP program, and participation in EP drills and exercises
to verify ERO member proficiency
Perform Emergency Preparedness program benchmark
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study against known high quality performers
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nyaluate ERO training against benclunark plants
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Routinely use ERO for multi-disciplined scenario
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Bring offsite emergency dose calculation software into
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conformance with GPUN software configuration control
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Utilize external resources to supplement self assessments
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and internal QA audit efforts
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Conclusions
The full participation biennial emergency
preparedness exercise ofmarch 5,1997 revealed
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weaknesses.in the following areas:
- Scenario development, validation, and exercise control
and performance assessment
- Emergency Response Organization knowledge
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particularly in technical support and other analytical
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- Adequacy of GPUN management attention to the
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TMI emergency preparedness program
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- Internal self assessments of the quality of the
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emergency preparedness program
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Adequacy of the emergency preparedness program
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oversight by management including communication of
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Prompt remedial actions have been taken to ensure
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effectiveness of the Emergency Preparedness program
Long term management actions will ensure the on-going
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effectiveness of the Emergency Preparedness program
The lessons learned from the recent efforts-are being
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applied to the Oyster Creek Nuclear Generating Station
emergency preparedness program
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ENCWSURE 3
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Response to:
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Confirmatory Action
Letter 1-97-011
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May 28,1997
by Jeff Grisewood
Emergency Preparedness Manager, TMI
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Confirmatory Action Letter
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Item #1
Initiated immediate corrective actions
to address the Biennial Exercise
weaknesses and conducted training
for the entire Emergency Res,oonse
Organization.
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item #1
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Conducted Emergency Action Level training for
all key positions
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Improved Primary to Secondary leakrate calculation
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methods
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Re-assessed technical staffing and made
appropriate reassignments
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Modified procedures to ensure consideration of
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the Protective Action Recommendation process
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outside the 10-mile radius
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Conducted Emergency Response Facility coaching
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drills
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Confirmatory Action Letter
Item #2
Pedormed a root cause analysis.
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Used Human Performance Investigation Process
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identified root causes associated with specific
weaknesses and other Emergency Preparedness
related issues
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Conducted a management review of the
root cause analysis
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Presented results to the NRC at a public meeting
on April 30,1997
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Confirmatory Action Letter
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Item #3
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Conducted a remedial onsite exercise
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on May 13,1997.
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Used a multi-discipline team to develop, validate,
and evaluate the exercise
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Concluded that the corrective actions were effective
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Confirmatory Action Letter
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Item #4
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Discussed proposed corrective
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actions in a formal exit meeting with
the NRC Staff on March 17,1997.
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Confirmatory Action Letter
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Item #5
Provided GPUN's view on the
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significance of the exercise
weaknesses and why the corrective
actions would be effective.
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