ML20207B785
| ML20207B785 | |
| Person / Time | |
|---|---|
| Issue date: | 12/12/1986 |
| From: | NRC |
| To: | |
| Shared Package | |
| ML20207B778 | List: |
| References | |
| PROC-861212, NUDOCS 8612290098 | |
| Download: ML20207B785 (146) | |
Text
._
0 ENCLOSURE 4
/o an"%,,
b States Nuclear Regulatory Commission Incident Investigation Manual i
O TRIAL USE ONLY l
i i
1 incident investigation Staff l
O 041-PDR
... ~
L
,4 %
PREFACE b
?
Q
_ The objective of the-Incident Investigation Program (IIP) is to ensure i
that operational events are investigated in a systematic and technically sound 1manner to gather information pertaining to the probable causes of the events, including ~any NRC contributions or-lapses, and to provide appropriate feedback regarding'the lessons'of experience to the NRC, industry, and public. By focusing on probable;causes of operating events and identification of
-associated corrective actions, the results of the IIP process should improve
' nuclear safety by ensuring a complete technical and regulatory understanding of i
significant events.
. The IIP was established in response to needed improvements in the way
~
existing NRC investigations of significant operational events are conducted.
With respect to fact-finding and probable cause determination, the following
~1mprovements were incorporated:
separation of fact-finding and determination of probable cause from licensing, regulation and compliance activities to minimize the
(,yt conflict of interest caused by previous actions or inactions, and the
. potential for adversarial atmosphere in an investigation; a more structured and coordinated investigation focused on the determination of probable cause(s) of a significant event; (VA) freezing the plant conditions and personnel, if practicable, from a safety point of view as soon as possible after a significant event; investigators with more operating experience, appropriate practical technical expertiso, and more training in conducting investigations; and
' timely issuance and implementation of recommendations from an investigation.
Incident Investigation Teams (IITs) ensure that significant operational events are investigated in a manner that is timely, objective, systematic and technically sound; that factual information pertaining to the event is docu-mented; that probable cause(s) are ascertained; and that a complete technical and regulatory understanding of such event is achieved.
The. incident investigetion manual prescribes procedures and guidelines for the conduct of investigative activities of the Nuclear Regulatory Comission (NRC) IITs.
The purpose of this manual is to provide IITs guidance to ensure that NRC investigations of significant events are timely, thorough, coordinated, and formally administered. The procedures are intended to assist the investigation
- Refers to comment number contained in Resolution of Coments document. ;
s -
'(
)Lratherthanlimittheinitiativeandgoodjudgmentoftheteamleaderor
'x
' members; they should use their experience and those techniques that provide the most confidence in assuring the IIT objectives are achieved.
The incident investigation procedures were developed and organized by the Incident Investi.gation Staff (IIS) of the Office for Analysis and Evaluation of Operational Data. The procedures reflect the experience gained from previous
'IIT investigations and other pertinent investigations.
The guidelines contained within this manual will foster uniformity, consistency, and thoroughness in IIT investigations while permitting teams the flexibility to accommodate the diverse nature and scope of future investigations.
4V e
m
...eA W
7:
if e
1, 1
,/
j[\\V
_ TABLE OF CONTENTS p,>
sp Il i 4
~
i
- PREFACE
.c...........
~
'1.0fGUIDELINESFOR'ACTIVATINGANINCIDENTINVESTIGATION
- TEAM ; ( I I T )
- ........... :........ '........
1-1
-1.1. Purpose...._...........-............
1-1 T.
1.2 Background......_..................
1-1
~
1.3 Introduction........................
1-1 1.4 Selection and Secpe of Events for IIT Response......
1-2
- '1.5 :IIT Membership......................
1-3
.1.6 IIT Activation Process..................
1-4
~
1.7 Participation by Industry Organizations.........
1-5 a
1.8 : Augmented Inspection Team (AIT) Response.........
1-6 1.9 Upgrading.or Downgrading an IIT..............
1-10 L1.10 Exhibits n
1 U.S. NRC Region I Nondestructive Examination Van..
1-13
'2.
Generic Confirmatory Action Letter.........
1-16
-3 Sample Confirmatory Action Letter.........
1-18 4
Sample Order to Show Cause.............
1-20 5-Background Information for IIT Briefing......
1-23
[)
6 Sample EDO Nemorandum to Commission.........
1-24
' ' 2.0 GUIDELINES FOR CONDUCTING AN INCIDENT INVESTIGATION......
2-1 2.1 Purpose...........'...............
2-1 2.2 General.........................
2-1 2.3 ' Scope of the Investigation................
2-1 2.4 Team Leader Responsibilities...............
2-2 2.5 Role of the Region....................
2-3 2.6. Initial A::tions by the Team Leader............
2-4 2.7 Entrance Meeting with the Licensee............
2-5 2.8 Plant Tour of Equipment and Systems...........
2-7 2.9 -Interviewing Personnel'..................
2-7
-2.10 Sequence of Events....................
2-7 2.11 Development of the Quarantine Equipment i.ist (QEL)....
2-8 2.12 Responding to Press Inquiries..............
2-8 2.13 IIT Coordination Meetings................
2-9 2.14 Identifying Additional Expertise and Outside Assistance.
2-9 2.15 Industry Participation in the Investigation.......
2-9 2.16 Parallel Investigations.................
2-10 2.17 Status Reports......................
2-10 2.18 IIT Recordkeeping Activities...............
2-11
!^
2.19 Collection of Information................
2-11 2.20 Referral of Investigation Information to NRC Offices...
2-12
~2.21 Confidentiality.....................
2-12 2.22 Subpoena Power and Power to Administer Oath and Affirmation.......................
2-12 2.23 IIT Investigation Sequence................
2-12 f
4
-q TABLE'0FCONTENTS'(Centinued),
/%
1
)
L '"
2.24 Return Site Visit'....................
2-13
~
'2.25' Report Preparation and Presentation..-.........
2-14 2.26 Exhibits 1
, Bulletin Board Notice.........-......
2-15 2-Sample-Sequence of Events.... ~..........
2-16 3
Sample. Preliminary Notification Report.......
2-20 4
Records and Documentation Control..........
2-21
'5 Sources of Information...............
2-30 6
_ Guidelines for Referral of Investigation-Information to NRC Offices... -,.........
2-32 7
. Procedures for Granting and Revoking Confidentiality and Determining When the Identity of a Confidential
. Source May Be Released Outside of the NRC......
2-41 8'
Guidelines for Administering an Oath or Obtaining an Affirmation..............
2-49 3.0 GUIDELINES FOR CONDUCTING INTERVIEWS.............
3-1 3.1 Purpose.........................
3-1 3.2 ~ Background........................
3-1
'3.3 Guidance.........................
3-1 3.4 Exhibits 1
Guidelines for Review and Availability of Transcri pts...................
3-5 2
Handling Transcripts................
3-8 G
4.0 GUIDELINES FOR THE TREATMENT ~0F QUARANTINED EQUIPMENT.....
4-1 4.1 Purpose.........................
4-1 4.2 Background.........................
4-1 4.3 Quarantined Equipment List (QEL).............
4-1 4.4 Quarantined Equipment List Guidelines..........
4-2 4.5 Guidance for Developing Troubleshooting Action Plans...
4-3 4.6 Guidelines........................
4-3 4.7 Exhibits 1
Sample Quarantined Equipment List..........
4-6 i
2 Generic Guidelines for Troubleshooting the Probable Causes for Equipment Anomalies.......
4-8 3
Example Action Plans................
4-11 5.0 GUIDELINES FOR THE PREPARATION OF THE INCIDENT INVESTIGATION TEAM REPORT..........................
5-1 5.1 Purpose.........................
5-1 5.2 Background........................
5-1 5.3 Writing and Publishing Guidelines............
5-1 5.4 Report Writing Guidelines................
5-1 5.5 Graphic Guidelines....................
5-4 5.6 Publication Forms....................
5-5 L
5.7 Distribution of the Advance Copy.............
5-5 5.8 Distribution of the Published NUREG..........
. 5-6 5.9 Schedule.........................
5-6
, _ _ _ _ _.. _ _ _, _ _ ~
TABLE OF CONTENTS (Continu:d)-. )~q Page
.' t
)
(f -
5.10 Exhibits
-1 Sample Report Outline................
5-9 2
l Valve Symbols....................
5-10 1
3 Sample Report Transmittal Memorandum to the EDO...
5-17 APPENDICES A;
NRC Incident Investigation Program - Manual Chapter 0513 B.
.IE Procedure for Augmented Inspection Team Response to Operational Events.
IE Manual Chapter XXXX C.
Letter from W. J. Dircks to the Commissioners,
Subject:
Incident Inves-tigation Program, SECY-85-208, dated June 10, 1985.
l l-O v
I-5
[
d
f MWONLY
~ ~N GUIDELINES FOR ACTIVATING AN 7
J.
INCIDENTINVESTIGATIONTEAM(IIT)
.ss IIT Procedure 1
1.1 Purpose
To provide guidance to NRC management for activating an Incident Investigation Team (IIT) response to a significant operational event at an NRC-licensed facility.
1.2 Background
This procedure provides guidance for activating an IIT and selecting the number and kinds of expertise required for a timely, thorough and systematic investigation. The scope, objectives, authorities, responsibilities, and basic requirements for the investigation of significant operational events at reactor and non-reactor facilities. licensed by the NRC are defined in the NRC Manual Chapter 0513. "NRC Incident Investigation Program." The Executive Director for Operations (EDO) approves the investigation of a significant operational event by an IIT based, in part, on recommendations by NRC headquarters and regionai offices concerning the safety significance of the event. The EDO also assigns IIT members (including. composition) based on recomendations by senior NRC
. management.
O The Incident Investigation Program includes investigatory resp (onses by an and the less formal response by an Augmented Inspection Team AIT). The V procedure for an AIT response, developed and maintained by the Office of
-Inspection and Enforcement (IE), is part of the Incident Investigation Manual.
1.3 Introduction Activating an IIT in res;:onse to a significant operating event nomally involves the coordinated activities of the appropriate region, IE, Office for Analysis and Evaluation of Operational Data (AEOD), and Office of Nuclear Reactor Regulation (NRR).
If the affected facility involves safeguards matters or fuel-cycle, byproduct material, uranium recovery, or waste management licenseee,, the Office of Nuclear Material Safety and Safequards (NMSS) would also participate.
If a safeguards issue is involved at a reactor, both NMSS and NRR would participate. A Regional Administrator or Program Office Director initiates a conference telephone call among the Office Directors of IE, AE00, NRR and the Regional Administrator. Generally the originator of the call explains what is known abeut the event and why an IIT should be activated. The decision should include consideration of public health and safety (protection of public/ environment, radioactive release or contamination) and should be based on the safety issues, potential generic implications, personnel errors, equipment failures associated with the event, and should take into account an individual's knowledge of the licensee's performance and judgment of the event's implications. This procedure attempts to structure the decision making by providing specific event characteristics on which to base a decision to activate an IIT.
l l
The conference telephone discussions have typically taken place after the plent has been placed in a safe, secure, and stable condition.
In any event, the IIT s
1-2
--[^ will be activated as soon as practical after the safety significance of the J
! operational event-is determined and will begin its investigation as soon as practicable to ensure that the facts, conditions, circumstances, and probable M
causes are ascertained.. If there is an NRC incident response, the investiga-
. tion will begin after it is deactivated.
1.4 Selection and Scope of Events for IIT Response The recomendation to the EDO for activating an IIT should include the identi-fication of the potential safety significance of the event. The threshold for activating an IIT is intended to be high and limited to those operational events which have significant safety implications. Historically, the events
' investigated by an IIT have, in general, involved multiple failures in plant
-systems that resulted in system responses that were not part of the design bases, and substantially reduced the safety margins that ensure public health and safety.
- Significant operational events that should be considered for an IIT response may include one or more of the following characteristics:
1.
A significant radiological release, a major release of special nuclear, source, or byproduct material, or uranium militailings to unrestricted areas, or personnel overexposure.
Personnel overexposure can occur as a result of an event involving a loss of control of radioactive materials and could involve facility personnel 1
O and/or members of the public. While, as of June 1986, no IITs have been V
established based on this criterion or characteristic, primary attention is given to potential offsite (i.e., public health) consequences and thus, should public health and safety be significantly impacted or threatened, an IIT response would be appropriata.
~
2.
Operation that exceeded, or was not included in, the design bases of the facility.
Such events include those in which both trains of a safety-related system were lost or events that were not analyzed in the Updated Safety Analysis Report:
e.g., the total loss of feedwater at Davis-Besse (1985), the precursor anticipated transients without scram (ATWS) at Salem (1983), the failure on demand of the safety injection system at San Onofre (1981), and the fire at Browns Ferry (1975).
3.
An evcot that reveals a major deficiency in design, construction or operation having potential generic safety implications.
Representative events having this characteristic are the loss of integrated control system at Rancho Seco (1985), the failure of the reactor cavity seal at Haddam Neck (1984), the inadvertent criticality durin refueling with the reactor vessel head removed at Vermont Yankee (1973 and Millstone (1976), and the water hamer event at San Onofre (1985.
4.
An event that exceeds a safety limit of the licensee's Technical Specifications.
1-3.
~
Safety limits are defined for each reactor in the technical specifica-
-(O tions, e.g., for a PWR, reactor coolant system pressure greater than 2735
.( #L
- psig, or the combination of thermal power, pressurizer pressure, and the
~ ^
highest operating loop coolant temperature (T average) exceeding the
. appropriate limit for n and n-1 loop operation. An example for a BWR is the Oyster Creek loss of coolant event (1979) which exceeded the safety limit for minimum inventory requirements.
5.
A significant loss of fuel integrity, of the primary coolant pressure boundary, or of.the primary containment building boundary of a nuclear reactor.
Events with this characteristic include the steain generator tube rupture at Ginna (1982), the loss of coolant outside the containment structure at Hatch'(1982), and significant pump seal leaks at Robinson (1981) and Arkansas (1980).
6.
Loss of a safety function or multiple failures in systems used to mitigate an actual event.
Events with this characteristic include the failure of the auxiliary feedwater system at Davis-Besse (1985), the partial failure to scram at Browns Ferry (1980), the precursor ATWS event at Salem 1983), and the failure of the safety injection system on demand at San Onofre 1981).
3 7.
An event that led to a site area emergency.
This type of event would involve activation of the NRC Operations Center C
and would normally involve multi-agency responses. The UF, cylinder rupture at the Sequoyah Fuels Facility in 1986 ic an exampTe of an event that falls in this category because the licensee's radiological contingency plan classified the event at least as a site area emergency.
8.
An event that is sufficiently complex, unique, or not well enough under-stood to warrant an independent investigation, or an event which warrants an investigation, such as an event involving safeguards concerns, to best serve the needs and interest of the Connission.
1.5 IIT Membership In addition to identifying the potential safety significance of the event, the recommendation to the EDO for activating an IIT investigation should address i
the types of expertise needed for the team. The IIT membership should be based on the following guidelines:
I 1.
Select the IIT leader and team members from rosters of candidates main-tained by AEOD. Candidates should be certified through formal training in incident investigation.
2.
Select an IIT leader who is an NRC manager from the Senior Executive 8
Service (SES).
p 1-4 MS.
Select IIT personnel based on their expertise, their potential contribut-ing to the event investigation, and their freedom from significant 1L')
involvement in the licensing and inspection of the facility involved or other activities associated with issues that had a direct impact on the course or consequences of'the event.
~
'4.
- Detemine the number of team members and their areas of technical exper-tise based on the type of facility and characteristics of the event.
For.
a reactor event, the team should include experts in reactor systems, human factors,(operations (licensed operator), and mechanical or electrical systems ISC or systems). Additional members could include specialists in physics, radiological assessment, health physics, safeguards, emergency planning, or other specialized areas.
5.
Obtain technical contract support to support the IIT as needed. Contrac-tor assistance should be limited to services that are not available within the NRC, e.g., independent laboratory analyses, computational support and testing. Within the NRC, there are also capabilities and expertise that can contribute to the IIT activities, e.g., the NDE vans (See Exhibit I for description of NDE van capabilities), control room simulators, photography, and computer analyses. The Incident Investigation Staff in AEOD will provide the resources and administrative support necessary to procure the services requested by the team leader. The Assistant General Counsel for Enforcement will provide legal assistance as necessary.
1.6 IIT Activation Process 1.
Upon their notification of a significant operational event, the Directors of NRR or NMSS, IE, AEOD and the Regional Administrator should assess the safety significance of the event to determine whether an IIT or an AIT is required. They assess the level of investigatory response based on the criteria in the NRC Manual Chapter 0513 and this procedure for activating IITs, and on the criteria in IE Procedure XX for activating AITs.
2.
Regional Administrators, in coordination with NRR or NMSS, and IE are to determine those operational events warranting investigation by an AIT; and as soon as it becomes clear that at least an AIT is warranted, pre-ferably before an AIT is actually established, consult with the Director of NRR or NMSS, IE and AE00 to consider whether an IIT response is appro-priate.
If an IIT is agreed upon, the initiating office makes that recomnendation to the EDO. Differences among NRR, NHSS, IE, AEOD and a Regional Office concerning whether an AIT or IIT is the proper response are submitted to the EDO for resolution.
l 3.
For events which the EDO agrees that an IIT is warranted, the EDO selects the IIT leader and team members.
The Director, AE00 will take the lead Administrator (i.e., in the Region where the event occurred)gional in coordinating with IE, NRR or NMSS, and the appropriate Re regarding the expertise and the availability of individuals for approval by the EDO.
4.
The EDO assigns a due date for the IIT report about 45 days after the IIT has been activated. The EDO should consider assigning the due date to O
coincide with a Monday so that all available administrative support will be directed to preparing the final report during the preceding weekend.
1-5 5.
After the IIT leader.and members have been selected, AE00 provides the V
Ladministrative support necessary to dispatch the IIT in a timely manner.
This support includes travel authorizations, tickets and advances during
-off-duty hours, logistics, and other site-specific infomation, including i
site access, and other site arrangements (guidance is provided in the i
Administrative Procedures).
6.- 'The Regional Admihistrator issues a Confirmatory Action Letter (CAL) to the affected licensee confirming the licensee's commitment that, within the constraints of ensuring plant safety, relevant failed equipr at is I
quarantined and subject to agreed-upon controls; that infonnation related to the event is preserved; and that the plant is maintained in a safe shutdown condition until concurrence is received from the NRC to restart.
Completion of an IIT investigation and issuance of the report is not necessarily required for plant restart. Exhibit 2 shows a generic CAL and 27
-Exhibit 3 shows a sample CAL that pas issued for an AIT response.
1 The CAL confims a licensee's statement of intent and action.
In the unlikely event that the licensee and Regional Office cannot agree on the actions that NRC believes are necessary, the Director of NRR or IE may issue an Order ensuring that infomation related to the event is preserved. Exhibit 4 shows a sample Order. Even where the licensee agrees to the tems of the CAL, those commitments may be confirmed by l
Order at a later timo if MC management deems it appropriate.
The Regional Administrator should ensure that a briefing package is O 7.
available to the IIT when it arrives onsite. This package should provide sufficient background information for IIT members to quickly grasp unique aspects of the plant design and relevant data related to the event. For power reactors, this type of information should be readily available from the resident inspector's office, where most of the data would normally be compiled as part of the resident inspector's onsite followup to significant events (IE Manual Chapter 93702). Exhibit 5 lists infomation that could be provided in the briefing package. The Regional Administrator should coordinate with the IIT team leader on the briefing I
package infomation necessary to support the IIT.
8.
The Director, AE00 prepares for the ED0's signature a memorandum infoming the Consnission of the activation of an IIT. Exhibit 6 shows such a sample memorandum. The Director, AEOD will also contact the Director, Office of Pubite Affairs (PA) and will assist in the preparation of the NRC press release.
i 1.7 Participation by Industry Organizations When an IIT is activated, industry representatives will be infomed and their participation will be requested. Their participation brings both an independent perspective to the investigation and expert knowledge of industry practices in numerous areas. In addition, industry participation ensures that t
licensees have immediate access to facts regarding the safety implications of I
the incident from which they may feedback to industry for iafomation, and for
[
initiating potential preventative and/or corrective actions. Their participation should help expedite the investigation by timely assessment of i
.._.., _.~ - _,_. _. _ __ _ _ _ _
=-
1-6
'(O significant issues and identification of the generic applicavility of the l
lissue. Industry participation is consistent with and fully supportive of the safety goals and objectives of the Incident Investigation Program.
i After the ED0 determines that an IIT regponse is warranted, the Director, AEOD will. inform the various industry aroups (INP0, NSAC, and the Owners' Group) regarding the IIT and invite their participation with the IIT in the investiga-tion. -The Director, AE00 will indicate the desired techr.ical expertise that the industry representative should possess to ensure a positive contribution to the IIT's activities. The industry contact has the responsibility to select the industry individual in accordance with the same criteria that the NRC representatives are selected, i.e., (1) specific technical expertise, (2) no
+
previous significant involvement with the affected plant or utility's activities i
and freedom from other significant activities associated with issues that had a direct impact on the course or consequences of the event, and (3) full-time participant for the curation of the IIT activities.
/
The industry contacts must satisfy the EDO or upon his direction, the Director, AE0D that their representative is suitably qualified and meets the selection i
criteria. The EDO approves the IIT members on a case-by-case basis, i.e., each is reviewed and approved individually.
After the EDO approves the composition of the IIT, all meir.bers will be advised of the location and time for the first IIT organizational meeting. The IIT leader will assign and organize the various investigative activities to the team members. All representatives should be relieved of other duties until the
- f
(
investigation is completed and the investigation report is issued, or they are released from the IIT by the IIT leader. The IIT leader may relieve from the l
x IIT any personnel who do not remain with the investigation until the completion of the report, or as an outgrowth of any action which the IIT leader may consider prejudicial to the conduct of the investigation.
I.8 Augmented Inspection Team (AIT) Response Events of lesser safety significance whose facts, conditions, circumstances and probable causes would contribute to the regulatory and technical understanding of a generic safety concern or another important lesson will be assessed by an AIT. The objectives of the AIT concept are to:
(1) augment regional personnel l
with additional personnel from headquarters or other regions for onsite fact-finding investigations of certain events; (2) communicate the facts surrounding the events investigated to regional and headquarters management; (3) identify AI and corimunicate ar.y generic safety concerns related to the events investigated l
to regional and headquarters management; and (4) document the findings and conclusions of the onsite investigation. AIT responses are addressed in an IE Manual Chapter which is included in the Incident Investigation Manual for information.
4
- The Incident Investigation Staff will maintain the list of industry Ocontactstobenotified.
l
I-7 fT The major differences between an AIT and an IIT are that an IIT investicates
- t,
) the most safety-significant operational events relative to reduced safety V mergins.
In addition, the IIT leader and me.nbers do nct and have not had significant involvement with licensing and inspection activities at the affected facility. An IIT investigation will normally assess the regulatory process prior to the event to determine whether the regulatory process contributed directly to the cause or course of the event. Table 1 further illustrates the differences between IIT and AIT investigatnry responses.
i O
r l
l l
l I
't
~
1:
1-8
)
Table 1 - Comparison of IITs and AITs Team Objectives IIT AIT Investigates events of potential
'Jaine safety significance at a facility or an activity licensed by the NRC to collect, analyze and document factual infonnation and evidence sufficient to determine probable causes, conditions and circum-stances pertaining to the event.
Team Activation The EDO activates an IIT based on A Regional Admini-recommendations from a Regional strator activates Administrator or the Directors of an AIT in consul-NRR, IE, NMSS or AE00.
tation with NRR or NMSS, and IE.
Events that represent a signifi-Events with a icant degradation in the safety lesser safety-margin available to protect significant thres-the public health and safety.
hold than an IIT C')'
gI -
would initiate an
(,
AIT. AITs are more formal and visible than routine inspec-tions.
Team Leader An SES member selected by the Usually a non-SES EDO from the IIT roster of person selected by certified investigators.
a Regional Admin-istrator.
Team Members A minimum of 4 to 5 members Regional staff with expertise in several rele-augmented by head-vant disciplines and having quarters and other participated in no prior regional staff, licensing / inspection activities and are relieved related to the licensee; members of normal duties, are selected from the IIT roster The team has no of certified staff and are minimum size and relieved of normal duties.
can include the project manager and resident inspectors for affected facility.
O
n_
~..
1-9 F
4 Tabel 1 - Comparison of IITs and AITs (Continued) s / Investigation IIT AE Scope Focuses primarily on An inspection deternining the causes and activity, the sequence of events as opposed results of which to violations of NRC rules and are handled requirements for enforcement through nor.1ici purposes.
organizational channels and procedures, excludes recom-mendations for enforcement actions,and does not examine the regulatory process.
~ Process Formal (transcribed inter-Less formal (tran-views and CAL or Order) and scribed interviews independent.
only if deemed necessary) and not independent.
Documentation NUREG report issued simulta-Special li.spection
_ [_T neously to EDO and Comission report of AIT y/
within about a5 days.
issued to Regional Administrator within 30 days.
Followup Actions Initiated by EDO to the Office Initiated by Region Directors and Regional or Program Offices Administrators.
through routine organizational channels and pro-cedures.
Administrative / Logistics Team response time Generally within 24 Generally within 24 after ar. event.
hours.
hours.
Travel funds and Provided by AE00.
Provided by Program administrative support Offices and Regions.
Frocedures for imple-AE00 procedures.
IE procedures, mentation e
O
1-10 i
Tabel I - Comparison of IITs and AITs (Continued)
' '~# Admin./ Logistics (cont.)
IIT AIT Regional Administra-Always Sometimes tor issues.Confinna-tory Action Letter to quarantine equipment or NRC Order issued.
r t-p Licensee personnel Always Not likely.
interviews transcribed.
(Transcriptswill be taken if deered necessary by regional adrainis-trators.)
Duration of site About 2 weeks About I week visit Press release Yes Regions may notify local press Team deployment Yes Yes e s highlighted in EDO 1
idaily staff notes.
O Preliminary Notifica-Yes Yes tions with periodic updates issued.
1
,,----,c-n.,-,._
1-11
^
b 1.9 Upgrading or Downgrading an IIT Adequate information is not always initially available or accurate enough to detemine whether the safety significance of an event warrants an AIT or an IIT. Thus, an AIT could be upgraded to an IIT or vice versa, based on
- conditions at the site.
In general, the safety significance of the event will ibe the criterion guiding ttra investigatory response.
- cause additional disruption to ongoing activities. Accordingly, the IIT leader
-must minimize the adverse impact of such a change by ensuring that frequent and a meaningful connunication occurs among the AIT, IIT, and the licensee during the critical transition period.
To upgrade an AIT to an IIT the following guidelines are used:
1.
As part of defining the scope of an AIT investigation, the Regionali Administrator would include a provision for the AIT leader to continually evaluate the safety significance of the event after arriving onsite.
Based on the AIT leader's assessment, the Regional Administrator would determine whether the event warrants consideration as an IIT response.
2.
Should the Regional Administrator detemine that the event warrants consideration as an IIT response, the process for activating an IIT would be followed as described previously in this procedure, e.g., a conference s
call would be held between the. Region, NRR, IE and AEOD (and possibly the
~
^
f AITleader).
3.
AIT members would be replaced ia accordance with the guidance described previously for IIT membership. The AIT leader would usually be replaced by an IIT leader selected by the EDO. All or some AIT members may be retained for the IIT based primarily on the independence of the individual with respect to their prior activities related to the affected licensee and the issues involved in the event.
4.
The AIT would remain onsite and assist the IIT until the IIT leader believed that a successful transition had been achieved.
To downgrade an IIT to an AIT using the following guidelines are used:
1.
In consultation with the IIT leader, the EDO decides that the event lacks the safety significance to warrant continuance as an IIT.
t 2.
The EDO assigns responsibility to the Regional Administrator to direct the IIT-to-AIT transition, including the release of the IIT leader and some or all of the members.
3.
The IIT leader would usually be replaced by a leader selected by the l
Regional Administrator. While all or some of the IIT members may be replaced, the IIT members would be expected to form the nucleus of the i
AIT.
4.
The AIT would then follow IE procedure XX which guides the response of the AIT.
l v.
e.-r
,-w- -,
- c-w c.
g_w,7-,-
pp
--,,-p.
gg-_
gn9y-.,.,.,,,-.,--,y
1-12 5.
The Director AEOD would prepare a memorandum for the ED0's signature
- eS-informing the Commission that the IIT has been de-activated based on the
- -(
)
lesser safety-significance of the event. The Director, PA would also be o' -
informed at this time.
O i,'
w-Y h
l l
~
\\
f l
i 1-13 Exhibit 1 ry Capabilities of the NRC - Region I
~
Nondestructive Examination Van Listed below are the inspection capabilities of the NDE Mobile Van which
- Region I has for perfoming direct independent examinations at licensee's facilities.
'1~.
Van
=
A 25-foot Dodge Van, equipped with a V-8 engine automatic transmission,
' two (2) holding tanks for gasoline, 85 gallon capacity, a 6.5 KW gasoline driven generator for heating, cooling and electrical van equipment. The 1
van is ' equipped with a supplemental heating system that operates from a 12V system using propane gas when it is not practical to operate the generator. or external power is not available.
- 2. -
Radiography
' Van is equipped with complete dark room facilities and isotope storage area.. Facilities to perfom and interpret radiographic examination to licensees inspection procedures or applicable codes, specifications and
-standards.-
.-3.
Ultrasonic
- (
The Van has two (2) Ultrasonic units, Sonic Mark I.
These instruments are portable battery operated capable of performing manual examination of most products' at a nuclear facility (with accessories).
4..
Thickness Gauge Portable hattery-operated instrument, digital readout for measuring metal thicknesses with the range of.050" to 10".
5.-
Liquid Penetrant Equipment to perform visible solvent removable and florescent penetrant testing.
6.
Magnetic Particle Equipment to perform (AC) yoke and (DC) prod magnetic particle examination.
- s 7.
Hardness Portable battery-operated instrument for measuring hardness of material which can then be converted to Brinell or Rockwell standards and approximate tensile strength.
I i
1 i
__-.,,m._
,.,---..r--.
-y
6
, Exhibit 1 (Continuid) 1,
, y 8.
Cable Tracer
(
)
Q'
, Portable, battery-operated inr.trument for locating and tracing electrical cables.
a.-
Tracing the paths of underground cable;
- b. -
Tracing the paths of wires; c.
Locating gas and water pipes; d.
Locating faults, shorts, opens and grounds; e.
Detemine depth of cables; f. Identify cables in groups.
9.
Digital Heat Probe Portable, battery-operated instrument for reading temperatures daring
-welding, post weld beat treat, etc.
- 10. Digital Multimeter Portable, battery-operated instrument for measuring volts, ohms, and amps of electronic circuits.
- 11. AMP Probe Kit Instrument used for checking line voltage and amperage, i.e., welding and magnetic particle currents.
- 12. ' Shore Durometer-CN.
(f Used to check hardness of rubber products.
- 13. Stero-zoom 7 Microscope & Accessories Direct applicable to observe defects in sample analysis.
- 14. Windsor Probe (Swiss Hamer)
Used to determin' the compressive strength of concrete.
15.
Infrared Thermometer Used for remote observation of materials temperature.
- 16. Surface Comparators Used to determine average surface finish of metals.
- 17. Megger - OHMS Generator Hand-cranked unit.for measuring ohms resistance of items such as heater bundles.
- 18. Ferrite Indicator (Severn Gauge)
A device used for indicating the ferrite content of austenitic stainless steel weld metals.
Exhibit 1 (Cintinued) 1-15
/ N '19.
Nortec-Eddy Current Machine
/
L d
Portable, battery-operated unit used for measuring paint thickness, can also be used to inspect material defects.
20.
R. Meter Portable, battery-operated instrument for locating rebar embedded in Concrete.
- 21. RPM Photo Tachometer Portable, battery-operated instrument used remotely, to determine motor RPM's, such as pump shaft speed.
- 22. Vibration Meter Portable, battery-operated instrument for measuring acceleration, velocity, and displacement of motors.
- 23. Fiberscope Instrument used to examine remote and hard to get to areas, such as inside pipe surface.
- 24. Surface Indicator Portable, battery-operated instrument used to measure surface finishes of machined materials.
- 25. Alloy Analyzer Portable, battery-operated instrument designed for rapid non-destructive onsite verification of type and element composition of many different engineering alloy's.
- 26. Dimensional Aids a.
Vernier Calipers b. Forma-gauge c. Micrometers d. Weld gauges e. Slope angle indicators f. Various coating thickness measuring devices
- 27. Digital Hand Torque Wrench Digital readout hand torque wrench for static torque measurements with accuracy and readability. A large LED digital display along with digital peak memory to make static torque measurements with accuracy with in 0.25%.
Y bU
i 1-16
^]
Exhibit 2 7
Generic Confirmatory Action Letter Docket No.
' Licensee Name]
l Address]
==Dear
- ==
On[date],[briefdescriptionofevent]. Because of the potential signif-icance of this incident to public health and safety, the NRC's Executive Di-rector for Operatiuns has formed an Incident Investigation Team (IIT) to investigate the circumstances surrounding the incident. -[Includeasappropri-ate a brief description of the event's significance].
This letter confirms the conversation on
[date]
between and of my staff related to this incident. With regard to the matters, discussed we understand that you have agreed to cooperate with the IIT and you have taken or will promptly take the following actions necessary to support this investigation:
g -
1)
The facility will remain in cold shutdown [or other appropriate mode description] until the Regional Administrator is satisfied that V)
(
appropriate corrective action has been taken and the plant can safely return to operation.
2)
The licensee will ensure that the equipment involved in the incident is not disturbed prior to release by the IIT.
In this regard, work in progress or planned on equipment that failed or malfunctioned 30 during the event, and had an impact on the sequence of events will be held in abeyance so that evidence of the equipment's functioning during the incident will not be disturbed. Personnel access to areas and equipment subject to this quarantine will be minimized, consistent with plant safety.
The licensee is responsible for quarantined equipment and can take action involving this equipment it deems necessary to:
(1) achieve or maintain safe plant conditions, (2) prevent further equipment degradation, or (3) test or inspect as required by the plant's 30 Technical Specifications. To the maximum degree possible, these actions should be coordinated with the IIT team leader in advance or notification made as soon as practical. The IIT team leader may authorize a release, in whole or in part, of those areas or equipment subject to the quarantine upon a determination that the IIT has received sufficient information concerning the areas or equipment requested to be released, or to permit necessary troubleshooting of the equipment, required testing or maintenance to be performed.
Exhibit 2 (Continurd) 1-17 3)
All records will be preserved intact that may be related to.the event f
Y and any surrounding circumstances that could assist in understanding V
the event. Such records shall be retained for at least two years following the event whether or not required to be retained by regulation or license condition.
4)
.The licensee wil.1 make available to the IIT for questioning such individuals employed by the licensee or its consultants and contractors with knowledge of the event or its causes as the IIT deems necessary for its investigation.
5)
The licensee will ensure that of any investigation to be conducted by the licensee or a third party will not interfere with the IIT investigation. The licensee will advise the IIT of any investigation to be conducted by the licensee or a third party. Reports-of such investigation will be promptly provided to the IIT.
Issuance of this confirmatory action letter coes not preclude the issuance of an order finalizing your comitments. The above comitments may be relaxed for good cause.
If your understanding differs from that set forth above, please call me immediately.
Sincerely, fm
[Name]
~
I Regional Administrator (d cc:
IIT Leader NRC Office Directors Regional Administrators c
O
1-18 b-Exhibit 3 N)
Sample Confirmatory Action Letter-Docket No. 50-373 :
- Docket No.< 50-374 Commonwealth Edison Company Attn:
Mr. Cordell Reed. Vice President j
P.O.. Box 767 i
C hicago, IL 60690 Gentlemen:
i
-This letter confirms the telephone conversation between Charles E. Nore11us and Ed Greenman of this office and Denny Galle and Denny Farrar of the reactor protection system (RPS) at LaSalle Unit 2 on June 1,1986.
At that time with the rector operating at about 83% power and with a feedwater
- surveillance test in progress,. cre of the reactor feedwater pumps increased speed and locked up, causing reactor water level to increase.
Upon reaching the high water level set point both pumps than automatically tripped, causing
. reactor water level to decrease.
There are indications that reactor water
. level may have decreased to nominal plus six inches (which is below the scram set point of 12.5 inches) but the reactor did not scram.
When the anomaly was discovered several hours after the event the operating staff initiated a m controlled shutdown in lieu of manually scramming the reactor and declared an alert.
The alert was terminated when hot shutdown was reached at about 9:30 a.m., June 2.
With regard to this event and to our A ugmented Investigation Team (AIT) which is being implemented to evaluate the root cause and signficance of the event, we understand that you will:
C 1..
. Determine the cause of the feedwater pump transient.
2.
Conduct a, thorough review to determine if water level decreased to or below the scram set point.
3.
'If water level decreased below the scram level, determine if a scram i
signal was received by the reactor protection system (RPS).
4.
If such a. signal was received, determine why the reactor did not scram.
\\-
l
'5.-
If such a signal was not received, or if water level did not decrease l-below the scram level, determine if any instrumentation indicated a low water level.
- 6.-
Maintain all affected equipment related to the event, including the RPS, in such a manner that it can easily be kept or placed in the "as found" l
con dition.
Therefore, minimize any actions which would destroy or cause l
to be lost (other than necessary to protect the health and safety of the public) any evidence which would be needed to investigate or
. reconstruct the event.
I CONFIRMATORY ACTION LETTER
Exhibit 3 (Continued) 1-19
)
CONFIRMATORY ACTION LETTER v
. Commonwealth Edison Company 2
7.
Advise the' AIT. team leader, Mr. Geoffrey Wright, of this office prior to condu~cting any troubleshooting activities.
Such notification will be soon enough to ' allow, time for the team leader to assign an inspector to observe the activities.
8.
Make available to the AIT all relevant written material related to the installation, testing, and/or modifications to the reactor level switches and the RPS.
9..
Review operator and shift personnel actions following the event and cetermine if these actions were in accordance with your procedures and policies.
Specifically, determine:
a.
What actions the on-duty operations staff took following the event.
b.
When and by whom the event was Mrst idendhed.
c.
If the eve.it was identified during shift turnover reviews or by some other method.
d.
Why event classification and notification took about 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />.
x 10.
Determine if this problem is unique to Unit 2 or if similar problems could occur on Unit 1.
- 11. Submit a formal report of your findings and conclusions to the Region III office within 30 days.
We also understand that startup of Unit 2 will not occur without concurrence of the Regional Administrator or his designee.
Such concurrence will also be obtained for Unit I should it be determined that Unit 1 is affected by this event.
Please let us know immediately if your understanding differs from that set out above.
Sincerely, James G. Keppler Regional Administrator cc w/ enclosure:
D. L. Farrar, Director of Nuclear Licensing G. J. Diederich, Plant Manager DCS/RSB (RIDS)
S Licensing Fee Management Branch
) Resident Inspector, RIII V Phyllis Dunton, Attorney General's Office.
Environmental Control Division CONFIRM ATORY ACTION LETTER
1-20 y
)
Exhibit 4
=q Sample Order to Show Cause UNITED STATES OF AMERIC A F
NUCLEAR REGULATORY COMMISSION
' In the. Matter of
)'
)
Docket No.
'[ LICENSEE'S N AME]*
)
~
.)
License No.
m
~[ Facility Name]
)
'^
7 ORDER TO SHOW CAUSE (IMMEDIATELY EFFECTIVE)
.I.
a
.-[ Licensee's name] (the Licensee) holds License No.
, which authorizes the-Licensee to operate the [name of facilityj
( Facility) in
[ location]
II.
[Brief description of the event in a paragraph or two]
- [_
\\
Q III.
T he NRC Executive ' Director for 0 perations has formed an Incident Investigation Team (IIT) to investigate the circumstances surrounding the
. incident. decribed in Section II of this Order.
An IIT was formed because
[ describe in one or two sentences the significance of the event].
The investigation is required to obtain _ necessary information to assure sufficient understanding of the cause of the event so that a determination may be :made as to what corrective actions will be sufficient to provide reasonable assurance that operation of the facility will not create an undue risk to the public health and safety.
The licensee's full cooperation is required during the investigation to permit a complete and timely investigation.
[ Indicate whether C AL was issued and reason why this Order is being issued in view of previous C AL; e.g., violation of terms of C AL or desire to fermalize C AL commitments by Order.]
i Accordingly, I have determined that the public health and safety re-
)
quires that the facility license be suspended until the IIT investigation is complete, the event evaluated, and appropriate corrective action taken and, therefore, that this order be immediately effective.
- Bracketed and underlined areas must be completed.
n Exhibit 4 (Continued) 21 4
g IV.
'In view of the foregoing, pursuant to sections 103[or appropriate section
' for materials license],161(b), (c), (1), and (o),182 and 186 of the Atomic
~
Energy Act cf 1954, or amended, and the Commission's regulations in 10 CFR
- 2.202 and Part 50 [or other appropriate regulations], IT IS HEREBY
- ORDERED, EFFECTIVE IMMEDIATELY THAT:
A)- The licensee' shall maintain the facility in cold shutdown [or other appropriate mode description] until the undersigned Director [or
- appropriate Regional A dministrator] determine
- that there is a sufficient understanding of the causes and consequences of the incident 'and sufficient corrective action has been taken such that resumption of operations poses no undue risk to public health and safety; B)
The licensee will ensure that the equipment involved in the incident is not disturbed prior to release by the IIT.
In this regard the licensee shall hold in abeyance any work in progress or planned on 3l equipment that failed or malfunctioned during the event, and had an impact on the sequence of events so that evidence of the equipment's functioning during the incident will not be disturbed.
This licensee shall minimize, consistent with plant safety, personnel access to areas and equipment subject to this quarantine.
The licensee is responsible for quarantined equipment and can take action involving this equipment o
it deems necessary to:
(1) achieve or maintain safe plant conditions, 3I f
(2) prevent further equipment degradation, or (3) test or inspect as D) required by the plant's Technical Specifications.
To the maximum de-gree possible, these actions should be ccordinated with the IIT team leader in advance or notification made as soon as practical.
The IIT team leader may authorize a release, in whole or in part, of those areas or equipment subject to the quarantine upon a determination that the IIT has received sufficient information concerning the areas or equipment requested to be released, or to permit necessary trouble-shooting of the equipment, required testing or maintenance; C)
The licensee shall preserve intact all records that may be related to the event and any surrounding circumstances which could assist in understanding the event.
Such records shall be retained for at least two years following the event whether or not required by regulation or license condition to be retained; t-i
- D)
The licensee shall make available to the IIT for questioning such individuals employed by the licensee or its consultants and contractors with knowledge of the
- event, its
- causes, or consequencies as the IIT deems necessary for its investigation; E)
The licensee shall ensure that any investigation to be conducted by 1
the licensee or a third party will not interfere with the IIT i
investigation. The licensee shall advise the IIT of any investigation to be conducted by the licensee or a third party.
Reports of such investigation shall be promptly provided to the IIT.
p
.g y...
m,
,,.7--.-,-..,.g.
,,.-C wm em 7
--*+-P-w- - -
--A
--r-
~ ' - - - + - '
~
Exhibit 4 (Continued) 1-22 y
O~
The licensee may show cause, within 30 days after issuance of this Order, why it should not have been required to comply with the provisions
- specified in Section III by filing a written answer under oath or affirmation setting forth the matters cf fact and law on which the Licensee relies.
The Licensee 'may answer this O rder, as provided in 10 CFR 2.202(d), by consenting to the provisions specified in Section III above.
Upon the Licensee's consent to the provisions set forth in Section III of this Order or upon failure of the Licensee to file an answer within the specified time, the
- provisions set forth in Section III shall be final without further order.
VI.
The Licensee, or any other person whose interest is adveuely affected by this Order, may request a hearing within 30 days of the date of this Order. Any answer to this Order or any request for a hearing shall be
. submitted to the Director, Office of Investigation and Enforcement, U. S.
Nuclear Regulatory Commission, Was hin gton, DC-20555 with a copy to the Executive Legal Director at the same address and to the Regional Administra-tor, [ Address]. If a person other than the Licensee requests a hearing, that person shall set forth with particularity the manner in which the petitioner's interest is adversely affected by this Order and should address the criteria set forth in 10 CFR 2.714(d).
If a hearing is requested by the Licensee or any person who has an interest adversely affected by this Order, the Com-pI mission will issue an order designating the time and place of any such hear-ing.
Any answer or request for a hearing shall not stay the immediate
,O effectiveness of Section III, of this Order.
In the event a hearing is held, the issue to be considered at such hear-ing shall be whether, this Order should be sustained.
FOR THE NUCLEAR REGULATORY C O MMISSIO N James M. Taylor, Director Office of Inspection and Enforcement Dated at Bethesda, Maryland, this day of 198 V
1-23
/~'s Exhibit 5 3
J'
'T
-Background Information for IIT Briefing (Compiled by Region) 11.
Preliminary Sequence of Events
- 2.
- Confirmatory Action' Letter and/or Order 3.
l Licensee Post-Trip Review
.4.
Control Room Operator Logs 5.
Computer Alarm Printout / Strip Chart Recordings
-6.
Applicable Licensee Procedures 7.
Applicable Licensee Technical Specification Requirements 8.
Preliminary Notification 9.
Licensee Press Release 10.
NR C Press Release s 11. Licer.see Organization Chart 12.
Diagram of Facility Layout 13.
Applicable Piping and Instrumentation Drawings
- 14. Applicable Vendor Drawings and Manuals 3
15.
S ALP Reports 16.
Applicable Inspection Reports 17.
Applicable Licensee Event Reports
- 18.. Applicable Maintenance Logs 19.
Applicable Electrical Logic Diagrams I
20.
Preliminary Operator Written Statements V
r i
I
,.-,n.--,,,
~.
1-24 Exhibit 6
(
Sample EDO Memorandum to Commission f
MEMORANDUM FOR:
Chairman Palladino
'_d Comissioner Roberts Comissioner Asselstine i f Com'ssioner Bernthal i I Comissioner Zech FROM:
William J. Dircks i
Executive Director for Operations
SUBJECT:
INVESTIGATION OF NOVEMBER 21, 1985 EVENT AT SAN ONOFRE S"-
UNIT 1 WILL BE CONDUCTED BY AN INCIDENT INVESTIGATION
$?.
TEAM (IIT)
At about 5:00am on November 21, 1985, San Onofre Unit 1 experienced a loss of an auxiliary transformer. Subsequently, a partial loss of electrical power g-occurred ar.d the control room lighting was lost.
Tne reactor was manually scramed which resulted in a short-term loss of all AC power. A sizeable, unisolable leak was then identified in the feedwater system which is used to maintain steam generator levels, and other failures were experienced in the plant equipment. The plant is now in cold shutdown.
There were no releases and adequate core cooling was maintained at all times.
Because of the nature and complexity of this event, I have requested AE0D to take the necessary action to send a five member IIT of technical experts to the site to:
(a) fact find as to what happened; (b) identify the probable cause as to why it hapoened; and (c) make appropriate findings and conclusions which would form the basis for any necessary follow-on actions.
The team will report directly to me and is comprised of: Thomas T. Martin, Director of the Division of Engineering and Technical Programs, Region I; Mr. Wayne Lanning, Chief, Incident Investigation Staff, AE0D; Mr. Steven Showe, Chief, PWR Training Branch, IE - Chattanooga; Mr. William Kennedy, Safety Operational Engineer, Division of Human Factors, NRR; and tir. Matthew Chiramal, Chief Engineering Section, AE0D.
The team was selected on the hases of their knowledge and experience in the fiel+ of reactor systems, reactor operations, human factors, and power distributic-ystems. Team members have no direct involvement with San Onofre Unit 1.
ihe team is currently enroute to the site.
The licensee has agreed to preserve the equipment in an "as-found" state un il the licer.see and the NRC Team have had an opportunity to evaluate the event.
The licensee's actions have been confirmed by the Regional Administrator in a Confirmatory Action Letter which was issued on
/ /
The licensee has also agreed to maintain Unit 1 in a shutdown condition until concurrence is received from the NRC to return to power.
O
~
Exhibit 6 (Centinurd)-
1-25 F~c L/
~
--(s_,<)The IIT. report will constitute the single NRC fact-finding investigation report. -It is expected t'1at the team report will be issued within 45 days frora now.
- m William J. Dircks Executive Director for Operations cc
- SECY~
OPE OGC ACRS PA Regional Administrators i
I
/'%
a i
l
BIACRfEONLY-F GUIDELINES FOR CONDUCTING AN INCIDENT INVESTIGATION (f
IIT Procedure 2
2.1 Purpose
To provide guidelines for conducting an Incident Investigation Team (IIT) investigation.
--2.2 General
-The objectives of the IIT are to:
(I) conduct a' timely, thorough, systematic, j
and independent investigation of safety-significant events that occur at facilities licensed by NRC; (2) collect, analyze, and document the factual information and evidence sufficient to detennine the probable causes, condi-tions, and circumstances portsir.ing to those events; and (3) determine whether the regulatory process prior to the event contributed to the cause or course of the event.
To meet these objectives, the investigation includes four major activities:
.the collection of data and information; the analysis and integration of the 1 facts;- the detennir.ation of findings and conclusions; and the preparation and
. presentation of the team's report.
~
[.]. These guidelines are intended to assist the investigation rather than limit the initiative and good judgment of the team leader or members; they should use their experience and those techniques that provide the most confidence in
( j' assuring that IIT objectives are achieved.
2.3 Scope of the Investigation The scope of an-IIT investigation should include conditions preceding the event, event chronology, systems response, human factors considerations, equipment performance, precursors to the event, emergency response (NRC, licensee, and Federal and State agencies), safety significance, radiological considerations, and whether the regulatory process and activities preceding the event contributed to it.
The scope of the. investigation does not include:
1.
Assessing violations of NRC rules and requirements; and 2.
Reviewing the design and licensing bases for the facility, except as necessary to assess the cause for the event under investigation.
Follow-up actions associated with the IIT process do not necessarily include all licensee actions associated with the event, nor do they cover NRC staff activities associated with normal event follow-up such as authorization for a
restart, plant inspections, corrective actions, or possible enforcement items. These items are expected to be defined and implemented through the nonnal organizational structures and procedures.
s
.~.
2-2 2.'4 Team Leader esponsibilities t
i i j The' team leader manages the investigation and delegates responsibilities to team members and to the Incident Investigation Staff. Specific responsibilities. include:
1.'
Directing and managing the IIT in its investigation and assuring that the objective and schedules are met for the investigation, as defined in NRC Manual Chapter 0513.
2.
Identifying, adding and removing equipment from the quarantined list within the constraints of ensuring plant safety and determining causes for
. equipment anomalies.
3.
Serving as principal spokesperson for the IIT and the point of contact for interaction with the licenses, NRC offices, ACRS, news media, and other organizations on tr~tters involving the investigation.
4.
Preparing frega at status reports documenting IIT activities, plans, significant findings, and safety concerns that may require prompt NRC action, e.g., issuance of Information Notices, Bulletins, or Orders.
5.
Organizing IIT work, including the establishment of schedules, plans, work tasks, daily team meetings, etc.
e 6.
Assigning tasks to team members in accordance with their knewledge, y
experience, and capabilities.
7.
Not permitting team members to dilute their investigative commitmerts with any other work assignments: their sole work activity should be incident investigation until the report is published.
8.
Administering resources provided and obtaining resources needed to properly carry out all necessary investigative tasks (e.g., obtaining additional team members, consultants, contractor assistance).
9.
Ensaring plant safety and that investigative activities do not unneces-sarily interfere with plant activities.
10.
Initiating requests for information, witnesses, technical specialists.
laboratory tests, and administrative support.
- 11. Controlling proprietary, safeguards and other sensitive information to "need to know" and cleared personnel.
- 12. Handling all communications with NRC headquarters and regional officials.
13.
Infonning the EDO of all significant findings, developments, and investigative progress. Requesting that the EDO grant an appropriate extension of time if established deadlines cannot be met.
- 14. Consulting frequently with IIT members to ensure a team approach to the p
investigation in matters such as revising the report outline, assigning member responsibilities, discussing the list of items that should be
~
y 2-3 closed out before_ leaving the. site, identifying investigatory milestones, NW)-
and seeking consensus on the contents and relevant information to include
(
in status and final reports.
~15.
Ensuring, in conperation with the team members and the technical
- writer / editor, preparation of the final report winin the due date established by the EDO.
16.-IntheeventthatItheIITresponse.ischangedtoanAITresponseorvice yersa, the team leader ensures that frequent and successful connunications I
occur among the AIT, IIT, and the licensee during the upgrading or down-grading to ensure an orderly transition.
(See Procedure 1, " Activating an IIT.")
1 l2.5 Role of the Region The responsibilities of the Region' during an IIT investigation are to:
(1) provide assistance in briefing and providing background information to the IIT
.when it arrives onsite, (2) provide onsite support for the IIT, and (3) identify and provide staff to monitor licensee troubleshooting activities to assess equipment performance.
In general, a regional representative will be designated by the Regional Administrator who will be responsible for ensuring a smooth and orderly interface with the IIT. The following is a list of regional activities accomplished prior to and during an IIT investigation to ensure a coordinated effort between the IIT and the Region.
O 1.
Prepare a briefing package prior to the IIT's arrival. See " Guidelines Q
for Activating an IIT" (IIT Procedure 1).
- 2..
Consider the need for a Regional Public Affairs Officer onsite.
J
- 3. -
Establish a single point of contact in the Region.
4.
Coordinate the Confirmatory Action Letter commitments for the Region with the licensee.-
5.
Negotiate with the licensee for sufficient office space for the IIT.
a.
Conference Room b.
Two rooms for interviewing c.
Adequacy of telephones (include at least one conference call telephone) 6.
Obtain secretarial support for IIT administrative workload. The secretary should safeguard transcripts and monitor interviewees during the review of transcripts. See " Guidelines for Conducting Interviews" (IIT Procedure 3).
7.
Make arrangements for obtaining escorted or unescorted site access for IIT members, as determined by the team leader.
8.
Schedule a tour of the plant.
i 9.
Have a regional representative attend all meetings between the IIT and the licensee.
J e
24 n 10. _ Provide regional. staff, as necessary, to monitor the licensee's
'3 i
troubleshooting activities of quarantined equipment. See " Guidelines for
&d
. the Treatment-of Quarantined Equipment" (IIT Procadure 4).
2.6 Initial Actions by the Team Leader 1.-
Prior to arriving onsite, the team leader should brief the team on the event, on the scope of the investigation, and on how the team will function.
2.
. During this briefing, the team leader should assign each team member a s,nacific area of responsibility, e.g., compiling the sequence of events, examining equipment performance, determining ^ the human factors issues.
3.
- Upon arriving at the site, the team leader should give priority attention to: (a) initiating a meeting with the licensee to learn what is known
- about the event and to reach an understanding with the licensee about the IIT's activities; (b) scheduling interviews with personnel having a direct knowledge of the event; (c) developing a detailed sequence of events; (d) comp (iling a quarantined equipment list and troubleshooting action plans; and e) responding to press inquiries.
4.
The team leader should ensure that arrangements have been made for those items requiring licensee assistance. These could include:
a.
~ Scheduling an entrance meeting with licensee management as soon as f3 practicable to discuss the event and the IIT investigation. Arrang-
- j ing for a meeting location in advance to allow sufficient time for stenographers to prepare to transcribe the meeting, b.
Scheduling a tour of the plant to begin immediately after the entrance meeting to inspect the affected systems and equipreent and to gain familiarity with the plant..
c.
Determining if the licensee wishes to provide photographic services 36 during the investigation.
d.
Establishing a preliminary schedule for interviewing personr.el having personal knowledge of the event (e.g., licensee staff and NRC residents).
(A list of potential interviewees should be provided to the IIT by the licensee pursuant to the Confirmatory Action Letter.)
L Interviewing should begir after the entrance meeting and plant tour.
The IIT should schedule the most senior personnel first and give special consideration to resolving conflicts between the interview schedule and employee work schedule.
5.
Incident Investigation Staff (IIS) will accompany and provide technical and administrative support to the IIT. The team leader should obtain additional administrative support from the Region, e.g., background documents, secretarial support, regional liaison. Such support could i
include:
a.
Providing a briefing package for each member of the team. See
" Guidelines for Activating an IIT" (Procedure 1).
_7 2-5 x,
h);t2'
- b..
Obtaining a meeting roon, to conduct IIT organizational meetings and d
' daily business; u
c.
Identifying and distributing telephone numbers and site locations to establish communications for the IIT;
'd.
' Confirming that.the room (s) for conducting personnel interviews are available as previously requested by the Incident Investigation Staff (IIS);and e.
Obtaining unescorted access to the protected area for IIT personnel is preferred. However, if time does not pemit the completion of training for unescorted access, the team leader should arrange to obtain escorted access.
2.7-Entrance Meeting with the Licensee The objectives of the entrance meeting are to:.(1)establishrapportwithand enlistthecooperationofthelicensee,(2)discussthepurposeandscopeof l
the IIT investigation (3) obtain the licensee's understanding of what occurred
'and why it occurred, and (4) request assistance from the licensee in obtaining information and resources. During the entrance meeting:
1.
The team leader will be the lead' spokesman for the NRC and will be responsible for directing the meeting and ensuring that all the major objectives of the meeting are covered.
2.
The stenographers must receive accurate information regarding the names of i
those speaking, their job titles, and their employers. For additional information, see the procedure entitled, " Guidelines for Conducting Interviews."
3.
One' team member should circulate an attendance sheet among those present at the meeting.
4.
The team leader should make an opening statement similar to the following:
1:
Tha purposes of the incident investigation team are to establish what i
happened, to identify the probable causes, and to document our findings and conclusions and issue a report within about 45 days. We will also be issuing status reports to our headquarters to keep them informed on the progress of our investigation. The investigation is not a re-analysis of l
the plant design, nor is it a compliance inspection, although our report L
can be used to form the basis for enforcement actions. We request that any information available as a result of your or other investigations be
-shared with us.
There are several things we would like to accomplish at this meeting, l
First, we want to get up to speed on your understanding of what occurred and your hypothesis of why it occurred. Second, we would like to establish l
our interfaces for the investigation where we can seek technical informa-I tion or ask for assistance such as escorts or looking at any particular pieces of technical documentation or equipment involved in the event.
2-6 h-Fin 111y, we would.like to review with you our investigation process which (V -).
- includes interviews, the troubleshooting of quarantined equipment, the
. handling of press inquiries, and the exchanging of infomation between your staff and the team. -That is our agenda for this meeting.
-5...
Licensee personnel should be allowed to describe what happened with few interruptions. The team should then identify additional personnel for interviews and followup topics to evaluate.
6.
The team leader should request that the licensee post a notice on all plant bulletin boards and major points of ingress and egress describing the purpose of the IIT investigation and soliciting information regarding the event (Exhibit 1).
7.
The' team leader should request that the licensee provide a preliminary list of all failed equipment and any equipment suspected of performing abnormally during the event. This list constitutes the initial quarantined equipment list (QEL). The list should be maintained by the licensee and lg be as current and complete as possible and should generally include only equipment significantly involved in the event that failed to perfom its 34 intended function. See " Guidelines for the Treatment of Quarantined Equipment," IIT Procedure 4.
8.-
The team leader should indicate that the licensee can take any action involving the QEL desired necessary to: achieve or maintain safe plant conditions, prevent further equipment degradation, or conduct testing or
.h inspection activities required by the plant's Technical Specifications.
l
('j To the degree possible, these actions should be coordinated with the team leader in advance or notification made as soon as practical afterward, 9.
-The team leader should confirm with the ifcensee that equipment on the QEL will be clearly identified and secured, and that no work will be initiated until an action plan for each component is developed and approved by the i
team.
I
- 10. The team leader should request that the licensee provide a preliminary sequence of events and update it as additional information and data become available.
- 11. The IIT should review with the licensee all aspects of the IIT investiga-tion process, including interviews, the troubleshooting of quarantined equipment, the handling of press inquiries, and the exchange of informa-s l
tion between the IIT and the licensee.
- 12. The IIT should request two copies of all documents (e.g. the computer sequence of events or data logging, relevant procedures, operating instructions, detailed plant design information), and arrange to have all documents sent to a designated receiving office.
- 13. The IIT should provide the licensee with a copy of the following documents:
O a.
Generic Guidelines for Troubleshooting the Probable Causes for I
Equipment Anomalies (see IIT Procedure 4. Exhibit 2).
l
if (y!
y 2-7 1:
f);.
b.
Example Action Plans used for troubleshooting quarantined equipment
(
(see.IIT Procedure 4, Exhibit 3).
c.
Guidelines for Review and Availability of Transcripts (see IIT Procedure 3 Exhibit 1).-
14a sThe team leader should request that the licensee establish a liaison for Mf: Tcommunications-with the IIT.
~
2.8. Plant Tour o'f Equipment and S.ystems 1.
The inspection ofLplant equipment and systen;s involved in the event and other relevant plant features (e.g., control room) should be scheduled after the entrance meeting and prior to personnel interviews.
- 2..
During the plant tour,' preliminary observatuns, issues and considerations should be written down as-a basis for questions to ask of licensee person-nel during interviews.
3.
Although the IIT will be provided with the necessary equipment to have photographic capability.if the licensee wishes to provide this service, 30 it should be given the opportunity to do so during the investigation.
hand, or person)quipment should contain something of known size (a ruler, Photographs of e to show the relative size of the object photographed.
-r 4.
The photographer should maintain a log that indicates the subject of each
.f photograph. Each photograph should be assigned a number and include a brief description of the subject. The resident inspector may be available to assist.in identifying infonnation for the photographer.
g
'2.9 Interviewing Personnel 1.
For guidance on interviewing, refer to IIT Procedure 3.
2.
Following the plant tour, the IIT should begin the interviews with the j
most senior individual with direct personal knowledge of the event.
3.
Individuals initially interviewed onsite often include: control room operators, the shift technical advisor (STA), plant / equipment operators, security personnel, site management, corporate personnel, health physicists, technicians ' casual observers / witnesses, NRC resident inspectors, and l
local officials and residents if appropriate.
4.
Later in the investigation, when attention is turned to the evaluation of pre-existing conditions or about how the regulatory process may have
- contributed to the event, additional interviews of licensee or NRC staff may be necessary. While the number of interviews should be minimized (to individuals with direct knowledge), cognizant management personnel should be interviewed to understand the context and priority of actions which were or were not apparently taken.
2.10 Sequence of Events 1.
The IIT should compile a detailed sequence of events based on the one provided by the licensee, on information obtained during interviews, and
2-8 p.
on material specified below and review it with the licensee. The IIT's j
)
sequence of events should be issued in a Preliminary Notification (PN)
L' within 3 to 5 days after arriving on site. The sequence of events is one of the IIT's most important findings.
It not only provides a step-by-step description of the event, but. it can help to focus the investigation,
-identify where more information is required, and generally provides an overall understanding of the event. Exhibit 2 contains a sample sequence
.of events.
-2.
The sequence of' events'should consider, resolve, and integrate relevant
-information and data. Such inforination could include:
a.
The licensee's sequence of events; b.
'The. output from the plant's data logging systems; Operators' plant logbooks and control room instrumentation records (i.e..stripcharts);and d.
Personnel observations from interviews.
'3.
Areas ( / uncertainty and contradictory information should be pursued and resolved by methods such as additional interviews, submittal of written questions to the licensee, or additional analyses of available information.
O4 h.
The sources of information identifying an event for the sequence of events should be documented for future reference.
i 2.11 Development of the Quarantine Equipment List (OEL) 1.
For specific guidance on the QEL and action plans, refer to IIT Procedure 4.
2.
As noted previously, agreements should be reached during the entrance meeting on the preliminary QEL and the. fact should be clarified that no work will begin prior to IIT approval of action plans.
l37 3.
The status of equipment on the QEL should be updated and revised based i
upon the sequence of events, personnel interviews, data reviews, etc.
4.
The' regional or resident's office should be requested to help monitor this equipment and the implementation of the equipment action plans.
2.12 Responding to Press Inquiries 1.
A news conference may be desirable.
If so, it should be scheduled as soon as possible after the arrival of the team leaaer. The Regional Public Affairs Officer will be available onsite to arrange the news conference and be the point of contact for the news media. The Regional Public Affairs Officer, IIT leader, and the licensee should coordinate press 38 conferences and responses to press inquiries to prevent the release of conflicting information.
l
--,--__---..--.n-_.-
2-9
/ w 2.
The IIT leader will be the lead spokesperson for IIT activities and should
.. ' V) limit discussions during and subsequent to the news conference to the El scope and purpose of the investigation, to the IIT process, and to the
. team's sequence of events.- Infomation provided to the press about the event should be identified as preliminary and subject to confinnation.
3.
If determined necessary, in consultation with OPA, a headquarter or a re-gional representative will be available to participate in the news confer-ence.
2.13 IIT Coordination Meetings' Periodic' progress meetings are an important cocrdinating technique for the IIT leader and a way of keeping each team member up-to-dete of the progress of the team's activities.. The team should meet at the end of each day to review results obtained by all team members and to plan the team's activities for the following day.
2.14 Identifying Additional Expertise and Outside Assistance s
1.
.The team leader should assess the need for additional expertise, particu-larly during the initial phase of the investigation.
4 2.
Obtaining additional NRC or contractor personnel should be considered if 1
certain aspects of the event are unique (e.g., security, water hammer, radiological, physics) and beyond the expertise of existing team members,
['
or if the complexity of the event is sufficient to warrant aoditional X
staff.
3.
NRC p rsonnel are available to conduct nondestructive examinations
-(NDE) activities on a wide variety of equipment and components. Mobile NDT vans can be sent to the site if apprepriate. NRC personnel are also available to conduct radiation surveys-and analyses. See Exhibit I to Procedure 1 for description of NDE capabilities.
4 4.
The team leader should discuss requests for additional assistance with the Director of the Office for Analysis and Evaluation of Operational Data (AEOD) or the Chief of the Incident Investigation Staff (IIS), either of whom will make the necessary arrangements with the Executive Director for Operations (EDO).
2.15 Industry Participation in the Investigation Industry representatives may participate as full-time members of the IIT.
In these cases, they will have responsibilities and privileges equal to other team I
i members.
2.16 Parallel Investications i
Normally, the IIT will provide NRC's primary investigation of an event. Conse-quently, it is expected that other investigations, by the licensee or by industry will be conducted in ways that do not interfere with the IIT. Should O the team's activities be impeded, delayed or limited because of parallel l
investigations, the team leader should try to resolve the problem with the
2-10 l
m licensee and/or appropriate organization.
If attempts fail or the situation
.I is not resolved to the satisfaction of the team leader, the team leader should 7#.
8
(
bring the-situation immediately to the attention of the Director of AEOD, who will coordinate the agency response to the situation with the EDO, Office of General Counsel (OGC), Regional Administrator, and other NRC offices.
In rare instances where a. parallel investigation is being conducted by another NRC office, such as the Office of Investigation (OI) or the Office of Inspector and Auditor (OIA), coo'rdination between the two investigative bodies, and between AEOD and the respective NRC office should be established to avoid hindering the. efforts of either investigation.
If the Institute of Nuclear Power Operations (INPO) is developing a Significant Event Report (SER) on the event, they will attempt to assure that the SER is not inconsistent with the facts of the event as understood by the g
IIT. This will be accomplished by INPO providing a draft of the SER to the licensee prior to issuance. The licensee will coordinate review of the SER with the IIT, and will assure any inconsistencies are made known to INPO so they can be resolved prior to issuance of the SER by INP0.
2.17 Status Reports 1.
The IIT should issue a Preliminary Notification (PN) Report at the end of the first day of the investigation. The PN will be prepared by the IIT on-site and transmitted to the appropriate Region for distribution. The PN should provide a brief description of the event, current plant status,
(
current licensee and IIT activities, and the names and phone numbers of
(
IIT contacts.
In general, the IIT leader and assistant team leader
- will serve as IIT contacts during the investigation. A sample PN is included in Exhibit 3.
The PN number is PNO-IIT-(year)-(number of this IIT this year)(letter identifying series of PNs).
2.
The IIT should issue subsequent PNs periodically (every 2 to 4 days while on-site) to update IIT activities for the regional and headquarter offices.
c 3.
When the sequence of events is well understood, the IIT leader should l.
suggest a conference call with the EDO, the Office of Nuclear Reactor Regulation (NRR), the Office of Inspection and Enforcement (IE), AE0D, and i
the Region to inform them of the team's information and to respond to their questions.
If in the course of the investigation significant new information is identified, the IIT leader should promptly inform the ED0
[
by telephone.
l l
l l
1
- The IIT will normally have an assistant team leader from the Incident Investigation Staff in AE0D.
74
=-
2-12 safety. The representatives will keep the IIT leader apprised of all infoma-m
' f Y tion pertinent to:the event. Common sense and good Judgment must predominate
[
A j in this matter. ~ Contacts with news media will be made in accordance with 7> 4,
'. established IIT procedures as described in Section 2.12.
1 i^
.Tne' team will collect relevant information and documentation upon which to base findings and conclusi.ons. The types of information that are generally-available and should be considered for use by the team are listed in Exhibit 5.
2.20 Referral of Investigation Information to NRC Offices
'During an IIT investigation,'the team may learn directly of allegations, potential wrongdoing or infomation that should be referred to other organizations for followup and disposition. The team leader has the responsibility to identify situations warranting referral and to make the appropriate notifications when referral is appropriate. Guidelines regarding referral of information to the Office of Investigations (OI), the Office of Inspector and Auditor (0IA), and the Office of Nuclear Material Safety and
. Safeguards (MSS) is contained in Exhibit 6.
2.21 Confidentiality
- The NRC's' inspection and investigatory programs rely primarily on individuals voluntarily providing accurate infomation. Some individuals, however, may
' provide needed information only if they believe their identities will be protected from pubitc disclosure, i.e., only if they are given confidentiality.
e In cases where the IIT leader believes that needed information will only be
/
-obtained by providing assurance that the NRC will not identify the individual (i.e., scurce of the information) the team leader should contact the Director of AE00, who will coordinate the situation with the EDO, OGC, and others in order to decide whether confidentiality can be granted by the team leader.
l Procedures regarding the granting and revoking of confidentiality (taken from NRC Manual Chapter 0517. " Management of Allegations") are contained in Exhibit 7.
t 2.22 Subpoena Power and Power to Administer Oath and Affimation Subpoena power is available to the NRC to assist it in gathering infomation which is related to the agency's public health and safety mission. Most investigations conducted by the NRC are accomplished without the need for a compulsory process because most interviews and infomation are given volun-tarily. Consequently, whenever information is considered to be vital to the investigation, and the individual or entity refuses to either be interviewed or I
provide documentary infomation, the team leader should immediately bring the i
situation to the attention of the Director of AE0D, who will coordinate the agency response to the situation with the EDO, OGC, Regional Administrator and the Director of IE.
In general, oaths are administered to ensure that individuals interviewed properly recognize the gravity of the situation. The point at which an oath is administered depends upon the circumstances surrounding the interview.
i During an IIT investigation, should the situation occur where the administering of an oath is seriously being considered, the team leader should contact the Director of AE0D, who will coordinate the situation and, if appropriate, obtair d
+. -., -,, - -
,,,._--.,.,-.-.m,,,-,_,.--.-,-x_,,--
- ~ -., - - - -
2-11
~
( 3 2.18 IIT Recordkeeping Activities fM )1.
During an IIT. event investigation, all interviews and some meetings will j
be recorded by stenographers who will prepare typed transcripts. The interviews and meetings are transcribed to assist the team in gathering information-to minimize note taking and to reduce inconsistencies and inaccuracies,
'AllinvestihativeinterviewsshouldfollowIITProcedure3, a.
" Guidelines for Conducting Interviews."
b.
~In general,'a record will not be made of discussions between the team and licensee perscnnel about routine administrative matters.
c.
All transcripts of interviews should be handled in accordance with the guidelines for review and availability of transcripts (see IIT Procedure 3, Exhibit 1), and the procedures for the handling of transcripts (seeIITProcedure3, Exhibit 2).
2.
The IIS management assistant or other NRC staff assigned to the IIT investigation, will be responsible for document control.
a.
The team members should ensure that all documents are provided to the Administrative Assistant for proper control and disposition.
b..
All documents received and reviewed during an IIT investigation will
.( mV) -
entitled " Records and Documentation Control" (Exhibit 4).
be handled in accordance with the IIS administrative procedure c.
Documents containing sensitive information (e.g., proprietary, safeguards) will be appropriately identified by licensee, properly marked on the outside cover, and stored in a safe or locking file cabinet maintained by the resident inspector's office.
d.
At the conclusion'of the onsite investigation, the boxes of documents should be shipped express mail to the Chief of the IIS at NRC headquarters at the following address:
i Chief, Incident Investigation Staff Nuclear Regulatory Comission 4340 East West Highway, Room 263 i
Bethesda, MD 20814 After the IIT departs the site, correspondence and requested documents should be expreis mailed to the above address.
2.19 Collection of Information All information obtained by team members will be brought to the attention of the IIT leader. Representatives may comunicate verified factual event-related information to nuclear industry organizations in coordination with the team l
l 1eader. This information should be transmitted only for purposes of preven-tion, remedial action, or other similar reasons to ensure public health and 1
2-13
)
(ma-delegation of authority to administer oath ano affirmction to the teamGuidelines for admi
' V; leader.
from-the OI Investigation Manual) are contained in Exhibit 8.
2.23 IIT Investigation Sequence 1.-
The initial onsite visit, normally lasting one to two weeks, is finished
'when'the team has completed the following activities:
a.-
A plant tour and inspection of equipment, b.-
All onsite interviews, c.
.A detailed sequence of events, d.
'The quarantined equipment list and corresponding troubleshooting j
action plans.
(If neither has been approved by the team leader, the IIT must establish an agreed upon schedule-for the licensee to i
transmit them to the IIT in Bethesda.), and e.
Arrangements with regional personnel for the monitoring component troubleshooting activities.
2.'.
The analysis and integration phase begins as infonnation is collected and continues in an iterative fashion throughout the investigation. Nonna11y the team will convene in Bethesda to analyze the relevant factual informa-tion and pursue the probable causes for the operating event. Well-chosen,
- p]
analytical methods,- when correctly applied, can guide the fact-finding s\\
-process and ensure a thorough, forthright, and hard-hitting investigatory analysis of the facts. Some of the analytical methods that were taught during the IIT training course and which have been proven valuable and
' effective in accident investigations include:
a.
Engineering judgment b.
Causal factors analysis c.-
Change analysis 1-l d.
Management Oversight and Risk Tree (MORT) analysis l-The results of these analyses should be integrated and compared to ident fy any(discrepancies or conflicts.e.g., from interviews, observations, data) is a The resolution of contradictory information activity necessary to ensure the success of the investigation and to provide an accurate and credible report. Analytical techniques, such as cross-checking information, should help to uncover inconsistencies and discrepancies so that they can be resolved.
i The team should use all practical means to resolve discrepancies, e.g.,
re-interview personnel, review and validate infonnation, separate facts from hypotheses.
If the discrepancy cannot be resolved, and is important to the outcome of the investigation, the report should so indicate and detail the attempts made to resolve it.
2-14 2.24 Return Site Visit.
'/
\\
' V Typically about 4 weeks after the event, the team should schedule a return site visit (as needed) to review any significant findings from the licensee's investigation, particularly from the troubleshooting activities conducted on quarantined equipment.
2.25-Report Preparation an'd Presentation Each team member will participate in a complete review of the team's investi-gative report for technical accuracy and adequacy of the scope of the investi-gation in his/her particular area of expertise. The IIT leader will obtain each team member's concurrence on the report signifying that the team member
/
has reviewed the report and that any differences of professional opinion have either been resolved or documented in an appendix to the report. Courtesy copies of the IIT final report will be provided to the participating team members.
An outline of the report should be developed before the conclusion of the entite investigation and assignments made of specific sections to team members. This phase of the investigation is addressed by an IIT procedure on report preparation (IIT Procedure 5), which includes a detailed schedule. The
- team leader will be expected to orally brief the EDO about the report within about 40 days, with the advance copy of the report sent to the ED0 and the Commission within about 45 days. Following issuance of the advance copy, the team will brief the Comission in an open meeting and subsequently the e Advisory Comittee on Reactor Safeguards (ACRS) on IIT findings and I
i conclusions. The team's report is also issued in final form as a NUREG document.
l I
l
- t O
~
2-15 Exhibit 1 j
Bulletin Board Notice F
--(CurrentDate)
POST ON ALL BULLETIN BOARDS
.T0: SITE PERSONNEL.
SUBJECT:
(DateofEvent),(EventDescription)
The subject incident is being investigated by an independent team of NRC the probable cause(pose of the team is to establish what happened, to identify
? personnel. The-purs). and to provide appropriate feedback to the industry
= regarding the lessons learned from the incident.
Anyone having information or observations that relate to this event, and
-wishing to communicate this inforination to the investigating team may contact
^(Team Leader) or (Assistant Team Leader) at (phone number) or (phone number).
Team Leader
' (.)
4 6
O
't 2-16 7
4
/A Exhibit 2
.] J[
_ Sample' Sequence of Events INCIDENT. INVESTIGATION TEAM PRELIMINARY, SEQUENCE OF EVENTS INITIAL PLANT CONDITIONS-
--Unit operating at steam state ~ power of 76% [710 MW(e)].
Reactor Coolant System (RCS) average temperature is 582*F.
- RCS pressure is.2150 psig.
~
- This plant does not have Main Steam Isolation Valves (MSIVs).
- The plant had started up on December 24, <i,985 following an outage of 2 days.
~
-IntegratedControlSystem(ICS)'infullautomatic.
. - The-Bailey computer was out of shrvice-(one of the plant's. two main computer systems'in the Control Room).. Consequently, the Bailey post-trip review, Bailey alarms printout, and Bailey input to the Interim Data Acquisition and j
Display System (IDADS) are not available.
IDADS inputs from sources other than the Bailey computer are available.
O DESCRIPTION OF EVENT--
DATA SOURCE g TIME
-Transient Initiation 04:13:47 " Loss of ICS or Fan Power" Annunciator Alarm.
IDADS Printout Loss of ICS is caused by the simultaneous deenergizing of all redundant ICS DC power supplies.
ICS demand signals go to midscale.
(The ICS works on +/- 10 volt scale, with zero volts'being 50% demand). The startup and Main Feedwater (MFW) valves close to 50%
because of this decrease in demand signal.
The loss of ICS power, however, causes the MFW pump speed to decrease to the minimum speed of 2500 RPM. With the plant initially at 76% power, this reduction in MFW flow increases RCS pressure.
The loss of ICS DC power also sends d'emand signals to one of two sets of Auxiliary Feed-water (AFW) flow control valves, the Atmos-pheric Dump Valves (ADVs) and the Turbine Bypass Valves (TBVs) to open to 50% demand.
e 4
Exh bit 2 (C'ntinu-d) 2-17 m
(
)'
(Note: The plant has two parallel sets of v
~AFW valves. One set is controlled by the ICS and one set is controlled by the Safety FeaturesActuationSystem).
- Operator / System Response to the Loss of ICS Power 04:13:?
Control room operators notice MFW flow Operator Statement decreasing ' rapidly.- Also, they notice RCS pressure increasing. Operators open the pressurizer spray valve in an attempt to stop the.RCS pressure increase.
Due to rapid overheating of the RCS by the reduction in MFW flow (it appears that MFW flow actually decreased to zero),
the actuation of pressurizer spray is not sufficient to reverse the RCS pressure increase.
04:14:01 The reduction in MFW oump speed causes a low IDADS Printout MFW pump discharge pressure of less than 850 psig which automatically starts the motor c -
driven AFW pump.
T 04:14:03 Reactor. trip on high RCS pressure. The turbine IDADS Printout C/
trip is also initiated by the reactor trip. A Control Room operator closes the pressurizer spray valve.
04:14:04 Peak RCS pressure of 2298 psig. Several Main IDADS Printout Steam Safety Valves are believed to have lifted and reseated early in the event.
04:14:06 AFW dual drive (i.e., steam & electric) pump IDADS Printout autostarts on low MFW pump discharge pressure (850psig).
This AFW pump is steam-driven throughout this transient.
-04:14:06 Peak RCS hot leg temperature of 606.5'F.
IDADS Printout Operator / Systems Response to the Plant Trip and Overcooling 04:14:7 Immediately upon reactor trip, many fire alams, Operator Statement the Technical Support Center (TSC) spray actuation alarm, the seismic trouble alarm, and Spent Fuel Pool (SFP) temperature high alarms are received. The significance of this is still being assessed.
v I
. ~. -.
=
~ Exhibit 2(Continu:dl 2-18 i "! L The operators perform the actions of the Emergency Procedure section E.01 (Reactor Trip Immediate Actions). This includes reducing RCS letdown flow.
Operators then proceed with Emergency Procedures section E.02 (Vital System StatusVerification).
. 04:14:113 AFW flow begins to both Once-Through Steam.
IDADS Printout Generators (OTSGs) through the ICS-controlled AFW Flow Control Valve.
04:14:25-Operators note pressurizer level decreasing, Operator Statement
' and fully open the "A" injection valve for more IDADS Printout makeup flow to RCS, 04:14:30 The loss.cf ICS power also results in loss of Operator Statement manual (i.e., hand) control of ICS controlled valves from the Control Room. Therefore, non-licensed operators are sent to close the TBVs, ADVs, and AFW flow control valves.
(Note: The ADVs and TBVs could have been shut from the. Remote Shutdown Panel. However, the operator failed to remember this fact).
V The operators recognize the beginning of an overcooling transient due to the open startup and main MFW valves the half open TBVs and ADVs, the open AFW flow control valves, along with MFW speed remaining at around 2500 RPM.
04:14:48 _ Makeup tank (MUT) level decreasing rapidly.
Operator Statement Operators open the Borated Water Storage Tank (BWST) suction valve on the "A" side to provide an additional source of makeup water.
04:15:04 Operators start the "B" HPI pump to increase IDADS Printout makeup flow to the RCS from the BWST.
04:16:02 Operators trip both MFW pumps.
IDADS Printout /
Operator Statement MFW flow indication on the Control Room strip charts indicates about 3.5 million pounds per hour. However, this MFW flow indication passes through modules powered by ICS and, therefore, the loss of ICS power causes this indicator fail to midscale. The actual MFW flow rate indicated by the IDADS printout decreased to zero upon reactor trip and does not begin increasing again before the reactor operators trip the MFW pumps. The actual MFW flow rate v/
{
_..~-
~.
l Exhibit 21(Continued) 2-19 c ~
L
's(
remained at zero due to the increased pressure
\\
in both OTSGs and the low speed demand to both
' MFW pumps.
v.
6 0,
9 f
W l
i m,
i 1
a
--+----yv,-,y
,..,-e_.we-,w---e---,.e-~
-S-.i.--r-e
a--g-,%ww y-a---
g-
-w..e,--.-.
m-m----,-, - -.. - - -,,, -.,
m--
,.-.,-rw--e-me- - -m--e n-m ww-
m.
2-20
,[ j'
--(
i Exhibit 3
\\_) -
' Sample Preliminary Notification Report-DATE:
11/26/85 PRELIMINARY' NOTIFICATION O'F EVENT OR UNUSUAL OCCURRENCE--PNO-IIT-85-2B This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information presented is
. preliminary, requires further evaluation and is basically all that is known by the IIT on this date.
FACILITY: Southern Californie Edison Company Emergency Classification Unit 1 X Notification of Unusual Event Docket No.-50-206 Alert Site Area Emergency General Emergency Not Applicable
?
SUBJECT:
Status Report from NRC Incident Investigation Team
.TheIncidentInvestigationTeam(IIT)remainsonsitegatheringdata, conducting
~
V ] licensee action plans and analyzing facts.
interviews, inspecting equipment, meeting with the licensee, concurring in
'(
A preliminary sequence of events
' " has been developed by the IIT and is attached. A set of preliminary hypotheses explaining the'significant events has been developed by the IIT and are being investigated.
All interviews should be completed on November 27, 1985. All licensee action
. plans for further troubleshooting and uncovering remainir.y event related infonnation should be finalized on November 28, 1985. Assuming the combination of ~information possessed by the IIT and the licensee action plans to uncover additional facts appear adequate to project closure of significant open issues, the IIT intends to depart the site by December 1,1985, and to reassemble in Bethesda, Maryland.-
A final status report will be issued prior to the IIT's departure from the site.
CONTACT:
T. Martin W. Lanning 714-492-2641 714-492-2641 F
+
D
2-21
. [N Exhibit ~4
(,)
Records and Documentation Control
Purpose:
. To establish Incident Investigation Staff (IIS) guidelines for collecting and maintaining records, documents, data and other
'information.
. Procedure - General-L0ne objective of the Incident Investigation Team (IIT) is to collect, analyze and document sufficient factual information and evidence to detemine the probable causes, conditions, and circumstances pertaining to the event.
In
- order for the IIT to achieve this objective, it must preserve and control the information collected during the investigation. The IIT should take measures
.to assure that all evidence will be handled in a sys.tematic manner to minimize tha probability of lost information, and so that information collected during
-the progress'of the investigation is readily available and retrievable.
Ordinarily, the IIS members assigned to the IIT will be responsible for maintaining and controlling the information collected.
-Procedures
' Specific 1.
Documents containing sensitive information, (e.g., proprietary, safeguards) will be appropriately identified by the licensee and clearly p.
marked _on the outside cover.
o g
A 2.-
All documents containing sensitive information, including transcripts, will be stored in a safe or locking file cabinet maintained by the resident inspector's office.
3.
Access to sensitive information will be limited to IIT personnel who have the appropriate security clearance and on a "need-to-know" basis only.
4._ -At the conclusion of the onsite investigation, the documents containing sensitive infomation will be sent to headquarters where they will be stored in a safe maintained by the.IIS.
5.-
After the issuance of the IIT investigation report, any documents contain-ing safeguards information will either be turned over to the Office of Nuclear Material Safety and Safeguards for proper disposition or destroyed.
6.
Arrangements should be made with the licensee to have all documents pertaining to the investigation delivered to a designated office.
In general, the resident inspector's office will generally be designated as the central receiving office for all documents during the IIT investigation, unless other arrangements have been made.
7.
As a minimum, the licensee should be requested to provide two copies of each document submitted to the IIT. Additional copies will be requested, as needed, by the IIT.
Exhibit 4'(Continued) 2-22
/
( 8..
' All incoming documents will be numbered in the order in which they are (f
received.- The number should be placed on the upper right-hand corner of the document. One copy of the document will be made available to the IIT.
Additional copies will be made, as requested by the IIT. The record copy will be placed in a chronological file maintained by the IIS Management Assistant.
9.-
The team leader should establish a method to route incoming documents to the appropriate, team members. The team leader can review all incoming documents first and then decide on the proper routing disposition, or each team' member can periodically review a printout of the document file to
' detonnine if they need to review any of the incoming documents. Whatever method the team leader chooses, it is important that information is disseminated quickly and to the proper team members for review.
110. When the incoming documents are numbered, the document name will be entered into a document file maintained by the IIS Management Assistant.
Data entered into the file must be sufficiently accurate to uniquely identify the document.
(When possible, the reference format style in the NRC Style Manual. NUREG-0650 and in NUREG-0650, Supplement 1 should be used.) The document file will be updated periodically and the IIT will be provided with a printout. Enclosure 1 shows a sample document file.
The listing of documents, or " bibliography" is used primarily by the IIT to retrieve documents from the IIT document file. After the investiga-tion, the bibliography is used by the Public Document Room in making the N)f collected information available to the public.
sv 11.
Identification and labeling of all photographs are essential. Enclosure 2 shows a sample log sheet that should be filled out by the photographer when each picture is taken.
If time or other circumstances do not permit the log. sheet to be filled out when the pictures are taken, the photographer can use a mini-cassette recorder to record the relevant information about each picture taken. The IIS Management Assistant or a designee will then transcribe the tape and fill out the lot sheet.
- 12. The photographs should be delivered to the IIS Management Assistant or 2
designee, who will stamp each photograph on the reverse side with the date it was taken and where it was taken for filing in a chronological file.
i
- 13. All transcripts of interviews should be handled in accordance with IIT l!
Procedure 3, Exhibit 2 entitled " Handling Transcripts".
- 14. At the conclusion of the onsite investigation, the boxes of documents should be shipped express mail to the Chief, IIS, at the following address:
Chief, Incident Investigation Staff Nuclear Regulatory Commission 4340 East West Highway, Room 263 Bethesda, MD 20814 l
- Exhibit 4 (C ntinu?:d).
2-23
- ,.g,
i T i
After the IIT leaves the site, correspondence and requested documents
\\f should be express mailed to the above address.
- 15. Document control'at NRC headquarters will be handled in a similar manner.
- 16.; After:the.IIT report.has been issued, the IIS will erke the following arrangements for archival requirements of all records and documents:
a.-
Three copies of all original documents will be made.
b.-
A copy of each 'of the documents will be transmitted to the Public Document Room (PDR), the appropriate local PDR, and to the Document Control Desk for inclusion on the Document Control System.
1 c.
The originals will remain with the IIS and placed on file for future reference.
I i
t b
O
--e- - - - - - - --. - - - - -..--- - - - - - - - -. - - -,--
,----.,r
,,-,-.r-,,em,....-,--
.w--.--
Exhibit'4(Continu-dl 2-24 d
i
)
Sample Bibliography
' Title.-
s1.
ActionListsi-12/28/85 1300 hrs.
01/02/86 - 1200 hrs.
01/03/86 - 1400 hrs.
01/04/86 - 1400 hrs.
01/05/86 - 1200 hrs.
01/06/86 - 1100 hrs.
01/07/86 - 1200 hrs.
01/08/86 - 1430 hrs.
01/10/86
'1600 hrs.
01/14/86 - 1400 hrs.
01/16/86 - 1200 hrs.
01/28/86 - 1600 hrs.
02/04/86 1600 hrs.
2.
Control Room / Shift Supervisor Logs 12/25/85 - Shift 1, 2, & 3 12/26/85 - Shift 1, 2, & 3
(,))3.-
i Personnel Statements S. Wood - SS C. Williams - SCR0 G. Simmons - STA (SCRO)
B. Nash - CR0 R. Wolfe - CR0 D. Nelson - PPH A. Jennings - A0 M. Peterson - EA D. Jenks - EA D. Lucht - WH G. Kovach - EA B. Chun - I&C Tech.
~W. Morisawa - SS 4.
October 2, 1985 Trip Analysis - From Licensee's Trip Report -
Overcooling Event 5.
Chemic.al Radiation Log:
12/26/85 - 0045 to 0515 hrs.
6.
Licensee's Preliminary Sequence of Events Current as of 12/26/85 - 1100 hrs.
Chronological Sequence of Events - Current as of 12/29/85 - 1700 hrs.
Revision 1 - Current as of 12/31/85 - 1600 hrs.
O Revision 2 - Current as of 01/04/86 - 1600 hrs.
Revision 3 - Current as of 01/05/86 - 0900 hrs.
~ -
- Exhibit 4 (Continu d) 2-25
,3 SI
[7.
Description of Integrated Control System Power Distribution KJ
" 8.
. Plant 0rganization Chart 9.
1EB 79-27 and Associated Infomation 3
V
.10.-
'OcenseeResponsetoIEB79-27
- a 2/22/80.
11.
Licensee Response to IEB 79-27
'12.
, Trend Recorders-from Control Room / Graph's from IDADS Points 13.
IDADS Alam Print Out
' Start Time - 11:22:40. 12/25/85 to End Time - 12:24:53, 12/26/85 r
114.
Emergency Operating Procedures 1,2&5 Rules 2 & 6 15.
P&ID Drawings
-P520 - Reactor Coolant System, Sheets 1, 2 & 3 M521-- Makeup and Purification System, Sheets 1, 2 & 3 M526 - High Pressure Injection and Makeup Pumps
/Q M532'- Steam Generator System i)
M533 - High Pressure Feedwater Heater System, Sheets 1-5 M534 - Low Pressure Feedwater Heater System, Sheets 1-5
~
16.
Procedures Applicable to the Event A 71 B.4, C.37 17.
' Systems Training Manual Chapters 0, 22, 32 18.
A0/EA Logs 19.
Shutdown Outside Control Room C.13a C.13b 20.
Annuncistor Procedure Manual Panel #2PSB 21.
Work Request 12/26/85 - #109621 3/13/80 - #45622 22.
AP.28 - Initial Post Trip Post Reivew & Revisions 12/26
'23.
News Release Greg Cook - Region V - 12/31/35 t
,,.. ~.
Exhib'It 4 (Continued)'
2-26
' (
[24.
Rancho Seco PNs-
--f AIT-85-92
~
IIT-86-01 IIT-86-01A 25.
.SMUD Office Memos-N. Brock to Operations 26.
Troubleshooting Action Plan ICS. Equipment Investigation ICS Equipment Investigation - Rev. 1 SMUD Office Memo - Transient Analysis Organization Troubleshooting, and Equipment Repair Following 12/26/S5 Transient System Response, Auxiliary Feedwater FWS-063, FWS-064 System Response, Auxiliary feedwater FV-20527, FV-20528 Memo to Action Item Lead Individuals from J. K. Wood -
Guidelines to Follow When Troubleshooting or Performing Investigative Actions into Root Causes Surrounding the 6/9/85 Reactor Trip 27.
Control Rcom Operator Relief Checklists 28.
-IDADS Computer Point Identifications
-/N 29.
IE Ir,tormation Notice No. 86 Loss of Power to Integrated Control System at Pressurized Water Ret.ctor Designed by Babcock and Wilcox 31.
Incident / Complaint Report 12/26/85 - 0414 hrs. - Unusual Event / Medical Emergency / Contaminated Firewatch 32.
Findings, Corrective Actions and Generic Implications Report - Toledo Edison 33.
. AFW Flow Calculations During Post Trip Recovery of 12/26/85 j
m 34.
OTSF and Main Steam Analyses 01/02/86 35.
SMUD Memo l
Colombo to Whitney - Tran:ient Cooldown Calculation - 12/31/85 36.
AFW Initiation Signal Report Prepared 12/28/85 - Approved 12/29/85 37.
B&W Initial Evaluation of 12/26/85 Transient 38 Reactor Shutdown Evaluation O.
12/31/85
..--.----i
Exhibit 4 (C ntinued) 2-27 m
(
)39.
T2J-10' Strip Chart 12/21/85 - 1418 s-12/29/85 - 012.'
40.
-IIT Sequence of Events Rev. 1 - 1/4/85 Rev. 2 r 1/5/86 Rev. 3 - 1/8/86 41.-
IIl Sequence of Events with Licensee Comments As of 0700 hrs. - 1/5/86 42.
Issues Arising From the Rancho Seco Incident Investigation 1/6/86 43.
Statement of Witness Dennis F. Venteicher 44.
SMUD Human Factors Issues List Control Room Workspace - Draft 45.
ICS Drawings - Babcock & Wilcox N.21.01 - 17 through 19 22 through 31
-(n -
32 - Sheets 1, 2 i
33 through 35 xj 38 through 43 45 - 5 48 51 53 through 54 56 through 61 63 through 76 l
77 through 85 Sheets 1, 2 86 through 87 Sheet I n
90 through 92 Sheet 1 94 through 111 Sheet 1 113 through 121 Sheet 1
~
122 sheets 1 - 5 127 137 through 138 46.
Nlil Drawings N.15.07 - 111 through 112 N.15.07 sheet 1 i sheet 1 sheet 1 sheets 4-39 sheets 41-51 sheets 54-69 0 sheets 63 Sheet 1, 2 - 82
. sheets 70 2
If Exhibit'4'(Continued) 2-28
\\
N.15.07 100 - 101 (j 132 - 170 181 - 212 N.15.08 51 47.
'SMUD Transient Evaluation -
Rapid Cooldown Incident 3/20/78 Volume 1 & 2 48.
B&W Letter F. R. Burke to G. Coward '
Initial Evaluation of Fuel and Primary System Components for December 26, 1985, Rancho Seco Transient 49.
MSRC Meeting Notes 04/7/78 05/2/78 06/15/78 06/19/78 50.
Figure Showing Handwheel Operation for Auxiliary Feedwater Control Valves 51.
Maintenance Instructions for Troubleshooting AFW' Manual Valves Nos. FWS063/FWS064 O ) 52.
Memo Dated 06/29/84 tor Gary Holahan and John Stolz, NRR from
(.v Fausi. Rosa and Charles E. Rossi, IE - Loss of NNI Power Following the Generator Hydrogen Explosion and Fire on March 19, 1984 53.
Memo Dated 08/03/80 for Harold R. Denton, NRR from Roger J. Mattson, Task Force (NUREG-0667) port of the B&W Reactor Transient Response NRR - Review of Final Re 54.
Memo Dated 03/06/81 for S. Hanauer, DHFS, D. Ross, DSI, R. Vollmer, DE and T. Murley, DST from Darrell G. Eisenhut, DL - NUREti-0667 Implementation Plan 55.
Memo Dated 06/03/81 for Harold R. Denton, NRR from Darrell G.
Eisenhut, DL - NUREG-0667,." Transient Response of Babcock & Wilcox Designed Reactors" Implementation Plan 56.
Rulemaking Issue (Notation Vote) SECY-83-288 Dated 07/15/83 for the Commissioners from William J. Dircks, EDO - Proposed Pressurized Thermal Shock (PTS) Rule 57.
Memo Dated 01/08/86 for Harold R. Denton, HRR, fr'om Frank J. Miraglia, PWR Licensing B - Review of Cesign Basis for B&W Facilities 58.
Memo Dated 2/1/83 for Commissioner Ahearne from William J. Dircks, EDO - AE0D Report on Arkansas Unit 1 Overfill Event
,m
~
JExhibit 4-(Continued) 2-29 rs --.
, [
')
y-x_;
Photograph Log Sheet Investigation Title Page of Photographer Facility / Location Camera Type Lighting Type-Film Type-
.Date of Event-Time of Event tO i,vj Film Roll No.
Direction Date of Time of Camera Picture'No.
Scene / Subject Photo Photo Pointing
%s p
d I
.--n-.--.._,
.,,m--
a n.-..-,.._.
._n,-,,, - - - - _ _ _ _ - -_,,n,.
Y 2-30
)
Exhibit 5 Sources of Information Tne following are types of documents and sources of infonnation that typically have been.found useful by.IITs.
1.
Operating Data a.
Strip / Trend Recorder Charts b.
OperatingLogs(Operators,STA,LoadDispatchers) c.
Technical Support Center Computer Output d.
Process Computer Output (Alarms, Equipment Status, Core Maps, On-Demand Calculations, Sequence-of-Events) e.
Security Computer (Times of Personnel Entry / Exit) f.
RadiologicalSurveys(onsiteandoffsite) g.
LaboratoryTestResults(Chemical, Metallurgical, Medical) 2.
Records
- f t(,,)
a.
Maintenance b.
Surveillance c.
Training History d.
Design Reviews / Engineering Changes and Modifications e.
As-Built Drawings f.
Vendor Information and Manuals g.
Operating / Emergency Procedures h.
Emergency Response Plan 1.
Plant Safety Oversight Meeting Minutes j.
Technical Specifications k.
Quality Assurance Records 1.
Transcripts of NRC Operations Center Notifications Post-Trip Reports
\\ O m.
n.
Inspection Reports
Exhibit 5 (Continued) 2-31
-['M-
--() 3..
Photographs
' J 4.
Correspondence a.
NRC to the Licensee and Elsewhere b.-
' Licensee'to the NRC and Elsewhere c.
Vendor / Consultant
'd..
Reenactments and Demonstrations 6.
Results of Troubleshooting Activities.
7.
Preliminary Operatt r Written Statements g
i l
l l
a
--=
y
+
2-32
"~
q,3 n
4Sj Exhibit 6 Guidelines for Referral of Investication Information to NRC Offices
Purpose:
t To. provide guidelines to the Incident Investigation Team (IIT) leader regarding l
referral of. items to the Office of Investigations (OI), the Office of Inspector and Auditor (0IA),and to the Office of Nuclear Material Safety and Safeguards (fMSS).
i
Background:
During the IIT process, the team may learn directly of allegations, potential wrongdoing or information that should be referred to other organizations for
-followup and disposition. The team must be cognizant of the type or nature of information or evidence that warrant referral to other organizations, and alert
'to identify, collect, and preserve this information during the IIT's r
activities. The team leader has the responsibility to identify situations J
warranting referral and to make the appropriate notifications when referral is appropriate.
{jReferralsto0I The Office ~of Investigations (OI) conducts inquiries and investigations of allegations of wrongdoing by non-NRC organizations and individuals, e.g., NRC licensees, applicants, and their contractors and vendors.
In general, this will.invo!ve matters that indicate there was a deliberate act of breach of an NRC reqairement. The following examples (taken from the OI Investigation Manual) should guide the team in identifying matters that are appropriate for referral to 01:
1.
Prior knowledge of NRC requirements by.esponsible personnel
'(expertise in the nuclear industry, position, and responsibility of the individuals within the organization, etc.) and a deliberate or conscious decision not to act accordingly; 2.
Documents showing prior knowledge of wrongdoing and failure to report; 3.
'Being placed on notice of noncompliance from an authorized source and i
failure to take corrective action; 4.
A record of some past similar experience indicating that the licensee knew the act was wrongdoing, yet proceeded regardless; 5.
Documentary or testimonial evidence eliminating the possibilities of O
the violation resulting from accident, worker carelessness, ignoranct, or confusion, etc.;
6.
Attempts at deception by a licensee or contractor, such as
[
.E$hibit' 6 (Continued)'
2-33 g
{
J
. atering down facts given to NRC, w
sa failure to record / document reports of noncompliance,.
efforts to contain, divert, or stop information from reaching
- NRC, efforts' to segregate, isolate, transfer, fire, intimidate, or
,O otherwise retaliate or discriminate against allegers surfacing or attempting to surface infomation of interest to the NRC, or for providing information of interest to the NRC, or for providing safety-related information to employers, and manipulation of documentation to confuse or hinder investigation / inspection efforts by NRC;
-7.
Documentation or testimony directly demonstrating that licensee management knew an act was wrong and against NRC requirements, but proceeded regardless; 8.
Any evidence of acts committed in the name of " expediency," with later claims that the comission was a result of confusion on the part of the licensee; and 9.
Falsification of documents.
O kj
- 10. Violations of federal, state or local criminal statutes.
If evidence of a situation, such as covered above, should be uncovered or implied by available infomation, the team leader should forward a memorandum to Investigation Referral Board with a copy to 01 (Addressee Only envelope),
requesting that 01 investigate the developed infomation. The fom attached to, " Procedure for Requesting 01 Investigations," should be completed i
and attached to the fomarding memorandum. Copies of the referral should be distributed consistent with Enclosure 1.
This referral should be made as soon as possible after the judgment is made that referral to OI is appropriate.
The team leader should notify the OI Field Office Director and the EDO of significant issues expeditiously.
In all cases this referral should be for-warded to the Investigation Referral Board before or at the time of release of the final team report.
Referrais to OIA l
The Office Inspector and Auditor (0IA) condtts audits and investigations regarding questions related to the effectiveness and integrity of NRC organizations, programs and contractors, and matters that involve tte conduct of NRC employees. Some examples of the issues that are investigated by OIA include:
1.
Possible irregularities or alleged misconduct of NRC employes, e.g.,
O improper release of documents to unauthorized individuals or organizations
[xhibit~6(Con'tinued)'
2-34 yx a(/p
- 6 submittal of false or misleading reports
.known' violations-of NRC requirements which were not documented or followed up on 0 -- ' evidence of obvious bias, favoritism, or partiality
, misuse of government resources.
2.-
Equal employment opportunity and civil rights complaints by NRC employees.
l 3.
Unreported property loss or damage due to actions by NRC employees.
4.
Potential conflicts of interests on the part of NRC employees.
If evidence of a situation, such as covered above, should be uncovered or implied by available infomation, the team leader should prepare memoranda to OIA and the EDO (Addressee Only envelope) referring the infomation to
. DIA for investigation. This referral should be made as soon as possible
- after the judgment is made that referral to OIA is appropriate.
-Referral to IMSS The Office of Nuclear Material Safety and Safeguards (NMSS) has the responsi-
- (
bility for matters involving safeguards against potential threats of theft and radiological sabotage and response to safeguards incidents. For the purposes
^
of the LIT, all safeguards-and security-related matters should be forwarded to
- the Director, NMSS (with copies to the EDO, Directors of IE, NRR and/or the appropriate Regional Administrator) for followup action and disposition.
.(Addressee Only envelopes should be used.)
IIT investigations which disclose potential evidence of sabotage, theft of nuclear material, or terrorism activities should be issnediately brought to the attention 1of the licensee so they ma (Copies to the Director, NMSS and as noted above.) y promptly notify the FBI.
If the IIT develops information that involves security, safeguards contingency, or safeguards plans that warrants followup, the team leader should prepare a memorandum to the appropriate Office Director for EDO signature describing the-issue for followup.
In all cases, situations where NMSS action and disposition may be appropriate should be documented before or at the time of release of the final team report.
Note: All documents containing safeguards information must be appropriately Tilenfified on the document as indicated below:
SAFEGUARDS INFORMATION: This document contains safeguards information and is exempted from public disclosure by 2.790(d) and 10 CFR 73.21.
Development of Information for Referral During its investigation, the IIT collects data and information from a variety of sources (e.g., interviews, plant records, docketed materials) that could
Exhibit 6 (Continued) 2-35 l
' provide the bases for referrals to other organizations. The existing procedure l (IIS Administrative Procedure 6) for collecting and meintaining records, documents, data, and other information should ensure that this infomation is preserved and available.
When a matter is identified for referral to either 01, OIA or NMSS, the IIT should develop the necessary supporting documentation to enable these organizations to ascertain whether a followup investigation is warranted. The IIT should pursue the' investigation to the point such that some evidence is available, that obvious leads have been identified, and that sufficient facts are available so that the appropriate organization can make an informed decision regarding the need for a timely followup. The level of effort expected by the IIT to judge the need for and document a referral is dependent on the nature and substance of the matter.
In general, the development of this information should not adversely impact the IIT schedule or objectives.
Schedule for Referrals As noted previously, the IIT leader will nomally forward matters for referral to other NRC offices by memorandum as soon as the evidence is available but not later than the time at which the final report is issued. Matters which, by their consequences, possess an actual hazard to public health and safety, property, or the environment, or is an actual threat to the common defense and l, security should be immediately communicated to the ED0 (and to the NRC Infoma-tion Assessment Team (IAT) through the Operations Center). The team leader should highlight all potential referral matters to the EDO during briefings of the IIT status and activities.
Public Release of Infomation There may be a need to protect certain information involved with a referral from premature public release. Consequently, if a referral has or will be made, the team leader should:
(1) discuss with the cognizant Office Director how the situation will be treated in the team's report, (2) assure that the Office Director receives an advance copy of the team's report, and (3) work with the Office Director and Office of General Counsel (0GC) to decide if there is a need to withhold supporting documents, e.g., interview transcripts, licensee documents, etc. from public disclosure at the time the team's report is publicly released.
v
Exh'ibii E (Continued)
~
Enclosurc 1 2-36
- [
UNITED STATES 8
)
NUCLEAR RESULATORY COMMISSION o
i.
.I WASMNGTON, D. C. 20655 July 5,1985 7 i: CC 1
MEMORANDUM FOR:'
Harold Denton, Director, NRR John Davis, Director, NMSS James Taylor. Director, IE Thomas Murley, Regional Administrator, Region I Nelson Grace, Regional Administrator, Region II James-Keppler, Regional Administrator, Region III Robert Martin, Regional Administrator, Region IV John Martin, Regional Administrator, Region V FROM:
William J. Dircks
' Executive Director for Operations
SUBJECT:
PROCEDUkE FOR REQUESTING 01 INVESTIGATIONS The purpose of this memorandum is to establish EDO policy for requesting investigations from 01.
f The primary purpose of an OI investigation is to provide information to
' assist the staff in making licensing and enforcement decisions. The staff
(' 'j has a significant interest in assuring that it obtains information from investigations necessary for decisions on a schedule that is compatible with the ?teff's reavletory needs. The Office of Investigations (OI) at the same time is responsible for the quality of investigations and, therefore, must staff and schedule investigations in a manner such that significant matters are thoroughly investigated on a timely basis.
In order for OI to understand the staff's investigatory requirements and to permit OI to exercise its judgments in an informed mar.ner, 01 must have sufficient information to enable it to reach infonned decisions as to whether to initiate an investigation and, if so, to determine its schedule. The attached form has been developed to assist 01 in securing the necessary infonnation to make its priority and scheduling decisions and to keep the various offices fully informed of requests for investigations. All applicable informatien must be provided on the form which should be reproduced and used when making requests. Copies should be sent to those indicated on the last page of the form. The requests should continue to be made by Regional Administrators to the OI field office and by Office Directors through the EDO to the Director of OI.
Upon receipt of the completed form. O! will evaluate the request and conduct consultations as necessary with the requesting office. OI intends to notify the requester within 30 days as to whether the matter has been accepted for investigation and, if so, the priority of the investigation and estimated schedele. OI will notify the requester if there is a substantial change in the estimated schedule.
If a request is not accepted. OI will provide the v
-_m,._--,_.,m...
' Exhibit'6 (Continued) 2-37 -
' (
A U-requester witn the basis for it:; decision. Copies of OI correspondence on scheduling and priorities will be sent to those indicated nn the request form.
Requests for investigations should continue to be made for allegations or staff concern of potential wrongdoing. Potential wrongdoing includes matters where regulatory violations appear to have occurred with some intent or purpose to violate requirements in contrast to violations involving error or oversight. The term should be construed broadly to capture cases where there may be an intent to affirmatively violate requirements as well as an intent not to comply with requirements where demonstrated by careless disregard or reckless indifference for regulatory requirements.
. Program offices in carrying out their oversight responsibilities must be aware within their program areas of matters being referred for investigations, the reasons for the referral, and the requested priorities. When offices initiate referrals, the appropriate regional or program office should be aware of the referral. Coordination and oversight are necessary since, due to resource constraints, all requested investigations may not be able to be
-ccaducted or at least not completed by schedules initially sought by the requester. The program offices are responsible to the EDO for assuring within their area of responsibilities that necessary investigations are conducted.
Recognizing there may be differences between the staff and OI on priorities and scheduling, regional administrators should notify the Director of the responsible program office of concerns in that area.
The Director O of the responsible program office, if not satisfied that an investigation priority or schedule established by the OI Director meets regulatory needs, must promptly notify the EDO.
4 I"
Questions concerning the above guidance should be referred to the Chief Counsel, Regional Operations and Enforcement.
In addition informal connunications are encouraged between the staff and OI to further assist in j
achieving the goals of an effective investigation program providing infomation to serve the staff's needs.
In six months, OI and the staff will reevaluate the effectiveness of the attached form.
p 1,
William. Dircks Executive Director for Operations i
Attachment:
As stated cc:
G. Cunningham, ELD i
- 8. Hayes,0!
O J
n
e
- - - - - - - - - -, - - - ~ -
- _rw,
,,,,,e-,,,-
,r,s
-v--~m.
1 m
.T'9
? xhibit 6 (Continu-d) 2-38 E
LIMITED DISTRIBUTION -- NOT FOR PUBLIC DISCLOSURE s,
Request No.
(Region-year-No.)
FROM:
REQUESY FOR INVESTIGATION
~
Licensee / Vendor / Applicant Docket No.
Facility or Site Location i
Regional Administrator / Office Date Director O
..i
(
l A.
Request q,)
!!h:t is the matter that is being requested for investigaticn (be as specific as possible regarding the underlying incident).
(
I B.
Purpose of Investigation 1.
What wrongdoing is suspected; explain the basis for this view (be as specific as possible).
4 W
LIMITED DISTRIBUTION -- NOT FOR PUBLIC D'ISCLOSURE W/0 OI APPROVAL
Lir.3 ILU U13in4Cu s a uls -- nue r un r u~it s b UAabLuJura.
2-(
2.
What are the potential regulatory requirements that may haave been
'N violated?
Ng 3.
If no violation is suspected, what is the specific regulatory concern?
4.
If allegations are involved, is there a giew that the aUlegation occurred? likely occurred not sure T-f likely, explain the basis for that view.
p C.
Requester's Priority 1.
Is the priority of the investi5ation high, normal, or icw?
2.
What is the estimated date when the results of the ir.vastigation are needed?
3.
What is the basis for the date and the impact of not meeting this date? (For example, is there an imediate safety iissue that must be addressed or are the results necessary to resolve any ongoing regulatory issue and if so, what actrions are dependent on the outcome of the investigation?)
W l
Q LIMITED DISTRIBifTIOR -- NOT FOR PUBLIC DISCLOSURE W/0 O! APPROYAL a
--c-,,
1.IMITED DISTRIBUTION -- NOT FOR PUBLIC DISCLOSURE
^
N D.
Contact v
1.
Staff members:
2.
A11egers identification with address and telephone number if not confidential.
(Indicate if any confidential sources are involved and who may be contacted for the identifying details.)
F.
Other Relevant Information b
~.
Signature O!(B. Hayes)Es)
- /
cc:
EDO (W.J. Dirc NRR/NMSS as appropriate (Denton/ Davis) *]. **/
IE(Taylor)*/.***/
OELD(Cunningham)
Regional Administrator **/ ***/,
- /
If generated by region.
1 T*/ If generated by. IE.
m/ If generated by NRR/NMSS i
O v
t THtTFD DISTRIBUTION -- NOT FOR PUBLIC DISCLOSURE W/0 01 APPRO i
~ ~ ' ' '
2-41 l
Procedures for Granting and Revoking Confidentiality and Determining When the Identity of a Confidential Source May Be Released Outside of the NRC Part I: General Or. November 25,1985, the Comission issued its Statement of Policy on Confidentiality (Policy Statement) to provide a clear, agency-wide policy on confidentiality. 50 Fed. Reg.48506(November 25,1986). There, the Com-mission recognized that its inspection and investigatory programs rely in part on individuals voluntarily coming forward with infomation. Some individuals will come fomard only if they believe their identities will be protected from public disclosure, i.e., only if they are given confidentiality.
Safeguarding the identities of confidential sources is, therefore, a signifi-
. cant factor in assuring the voluntary flow of such information. The.Colicy Statement applies to all Comission offices and directs those offices to make their best efforts to protect the identity of a confidential source. The following procedures are to be followed in implementing the Comission's Policy Statement.
Part II: Granting Confidentiality 1.
Confidentiality is not to be granted as a routine matter.
- Rather, confidentiality should be granted only when necessary to acquire information related to the Comission's responsibilities or where warranted by special circumstances.
It should ordinarily not be granted when the individual is willing to provide the information without being given confidentiality. Consequently, if an alleger is providing information willingly, confidentiality should not be granted and the individual should not be advised of its availability.
2.
If an explicit request for confidentiality is made, the request should not be automatically granted. Rather, infomation should be sought from the alleger to make a determination as to whether the grant of confi-dentiality is warranted in the particular circumstances at hand. The following information should be solicited from the alleger to assist in making this determination.
a.
Has the alleger provided the information to anyone else, i.e., is the information already widely known with the alleger as the source?
b.
Is the NRC already knowledgeable of the information, thereby obviating the need for a particular confidential source, i.e., why subject the NRC to the tems of a Confidentiality Agreement unless necessary?
c.
Does the alleger have a past record which would weigh either in favor of or against granting confidentiality in this instance, i.e.,
has the alleger abused grants of confidentiality in the past?
,v
Exhibit 7 (Continued) 2-42
{
/
)
d.
Is the information which the alleger offers to provide within the
(~,!
jurisdiction of the NRC, i.e., should be be referred to another agency?
e.
Why does the alleger desire confidential source status, i.e., what would be the consequences to him if his identity were revealed?
Depending on the information gathered by the authorized NRC employee, a determination should be made as to whether granting confidential source status would be in the best interest of the agency.
3.
When an alleger does not expressly request confidential source status, an authorized NRC employee may raise the issue of confidentiality in certain circumstances. Such circumstances can vary widely. Authorized NRC employees have discretion to raise the issue of confidentiality when in their judgment, it is appropriate. Considerations in making this judgment would include:
a.
When it Lecomes apparent that an individual is not providing information because of a fear that his/her identity will be disclosed.
b.
When it is apparent from the surrounding circumstances that the
[.y.,,,p interview being conducted in a secretive manner or is the alleger witness wishes his/her identity to remain confidential, e.g., is the (N
refusing to identify himself?
\\C) -
Once the issue of confidentiality is raised with the alleger and he/she indicates a desire for confidential source status, the same considerations that apply to an explicit request for confidentiality would apply here.
See Paragraph 2 above.
4.
When granting confidentiality, the following points should be discussed with the alleger.
a.
The sensitivity of the information being provided by the source should be explored with a view to determining whether the information itself could reveal the source's identity.
b.
The source should be informed that, due to the tight controls i
imposed on the release of his identity within the NRC, he should not expect others within the NRC to be aware of his confidential source status and it would be his re:;ponsibility to bring it to the attention of NRC personnel if he desires similar treatment for the information provided them.
c.
If inquiries are made of the NRC regarding his status as a confi-(
dential source, the agency will neither confirm nor deny his status.
t d.
The basic points of the standard Confidentiality Agreement should be l
revised t? it is not possible to provide the individual with a copy to read.
1 Exhibit 7 (Continued) 2-43 J.
An NRC employee wishing to grant confidentiality must either be expressly
~ delegated to do so or must seek authorization from the appropriate Office or Regional official. Authorization can be prearranged as circumstances warrant. This might include a planned meeting with an alleger. Office Directors and Regional Administrators are authorized to designate which NRC employees may grant confidential source status and/or further delegate the authority to do so. Authority to grant confidential source statet is to be documented in writing either through a standing delegation or an ad hoc authorization.
In special circumstances, an oral authorization is -
permissible if confirmed in writing. The standard Confidentiality Agree-ment-(Enclosure 1) is to be executed. The circumstances surrounding a grant of confidentiality must be documented in a memorandum to the Office Allegation Coordinator (OAC).
6.
In those circumstances where it is impossible to sign a Confidentiality Agreement at the time the infomation is obtained, e.g., when the information is obtained over the telephone, or in a location not conducive to passing papers, confidentiality may be given orally pending signing of the Confidentiality Agreement within a reasonable amount of time, generally two weeks.
If documentation is not completed in that time frame, the Regional Administrator or Office Director will determine if confidentiality continues. See Part III.
If confidentiality is granted orally, this must be innediately documented by the person
- 1 granting it and noted in the memorandum to the OAC.
Office Directors and Regional Administrators must be inforced of each grant of confidentiality. These senior officials must also approve any variance to the standard Confidentiality Agreement and each dental of confidentiality.
8.
The OAC of each Office and Region will maintain an accurate status regarding grants of confidentiality made by the particular Office or Region to include copies of signed Confidentiality Agreements. This file will be a Privacy Act System of Records and all normal security procedures for the protection of sensitive unclassified information will be applicable. A confidential source will be revealed within the NRC on a need-to-know basis only. Any employee with access to the confidential information must take all necessary steps to ensure that the infomation (identity, etc.) is not further disseminated.
(See Basic Requirement 054). With regard to protecting a source, an account should be taken of disclosing infomation which may reveal the source. Normally, the removal of the source name and identifiers will be adequate, but circumstances might exist where particular infomation itself may reveal the source.
A detemination regarding need-to-know is to be made by a senior Office or Region staff member at the Branch chief level or above or the OAC.
The individual making the need-to-know detemination shall provide the OAC with a record of persons to whom the access has been granted. The OAC is also responsible for maintaining secure files when files contain n\\
information which would reveal the identity of a confidential source and (d
marking such files "Contains information which would reveal the ioentity of a confidential source." Each employee who has access tc information which would reveal a confidential source, i.e., has been found to have a
Exhibit 7 (Continued) 2-44 I
([D need-to-know, shall take all necessary steps to prevent disclosure of the
()
.information to unauthorized personnel.
For example, when written informa-tion which would reveal a source is not being used, or is not within personal control of the NRC employee, it should be kept in locked storage.
9.
If at'any time for any reason confidentiality is breached or jeopardized, the appropriate Regional Administrator or Office Director should be infonned. The confidential source should be advised.
Part III. Revocation of Confidentiality 1.
A decision to revoke confidentiality can only be made by the Commission, the EDO, or the Director of OI or OIA.
In each case, only the office originally granting confidentiality can revoke that grant except that the Comission may revoke a grant made by any office. Confidentiality will be revoked only in the most extreme cases. Cases for consideration include where a confidentiality agreement is not signed within a reasonable time following an oral grant of confidentiality, or where a confidential source personally takes some action so inconsistent with the grant of confidentiality that the action overrides the purpose cf the confidentiality, e.g., disclosing publicly information which has revealed
[, )
his status as a confidential source or intentionally providing false
(.
infonnation to the NRC.
Before revoking confidentiality, the NRC will attempt to notify the confidential source and provide him/her with an opportunity to explain why confidentiality should not be revoked. All written connunications with a confidential source which require / request a reply are to be sent CERTIFIED MAIL-RETURN RECEIPT REQUESTED.
Part IV: Official Disclosures 1.
Disclosure to the Licensee or Other Affected Organization:
If the information provided by a confidential source involves a potentially significant and immediate impact on the public health and safety, the affected organization should be promptly informed to assure proper and timely action. In some cases, release of the information will compromise the identity of the confidential source.
In such cases, l
release should normally not be made unless the release is necessary to prevent an inaninent threat to the public health and safety.
In such cases, l
the EDO shall be consulted and efforts will be made to contact the confidential source and explain the need for disclosure. Consistent with j
the Commission's Policy Statement, however, disclosing information which l
would reveal the identity of a confidential source will be made only following best efforts by the agency to protect or limit the possibility of disclosure.
/^\\
N Exhibit 7 (:entinued) 2-45 I
2.
Other Disclosures:
NRC employees may be requested by Congress, State or Federal agencies to provide information which may reveal the identity of a confidential source. Each such request will he handled on a case-by-case basis.
Points to consider, however, are discussed below:
a.
Congres,s_
Disclosure to Congress may be required in response to a written Congressional request. The Comission will disclose the identity of a confidential source to Congress only if the request is in writing and it will make its best efforts to have any such disclosure limited to the extent possible. This might include assuring that the request is by Congress in its official, and not personal, capacity; the hand delivery of requested information directly to the affected Congress persen; and attempting to satisfy the request for information by not revealing the identity of the confidential source.
b.
Federal and State Agencies If another agency demonstrates that it requires the identity of a confidential source or infonnation which would reveal a source's
[)
('
identity in furtherance of its statutory responsibilities and that agency agrees to provide the same protections to the source's
/
("/
identity that the NRC promised when it granted confidentiality, the action office OAC will make a reasonable effort to contact the source to determine if he/she objects to the release.
If the source is reached and does not object, Office Directors or Regional Administrators are authorized to provide the information or the Identity to tha other agency.
If th'e source cannot be reached or objects to the release of his/her identity, the source's identity may not be released without Comission approval. The affected agency may then request that the Comission itself release the identity. Ordinarily, the source's identity will not be provided to another agency over the source's objection.
In extraordinary circumstances where furtherance of the public interest requires a release, the Comission may release the identity of a confidential source to another agency over the objections of the source.
In those cases, however, the other agency must agree to provide the same protections to the source's identity that were promised by the NRC.
V l
l
Exhibit 7 (Continued) 2-46
(
l j
C_onfidentiality Agreement I have information.that I wish to provide in confidence to the U.S.
Nuclear Regulatory Conimission (NRC).
I request an express pledge of confidentiality as a condition of providing this information to the NRC.
I will not provide this information voluntarily to the NRC without such confidentiality being extended to me.
It is my understanding that, consistent with its legal obligations, the NRC, by agreeing to this confidentiality, will adhere to the following conditions.
i (1) The NRC will not identify me by name or personal identifier in any f:RC initiated document, conversation, or conrnunication released to the public which relates directly to the infonnation provided by me. I understand the term "public release" to encompass any distribution outside of the NRC with the exception of Congress or State or Federal agencies which may require this infonnation in furtherance of their responsibilities under law or public trust.
(2) The NRC will disclose my identity within the NRC only on a need-to-know basis to the extent required for the conduct of NRC-related activities. Consequently, I acknowledge that if I have further contacts with NRC personnel, I cannot expect that those people will t /N be cognizant of this Confidentiality Agreement and it will be my f
l
Exhibit 7 (Continued) 2-47
)
responsibility to bring that point to their attention if I desire j
similar treatment for the information discussed to them.
1 (3) During the course of the inquiry or investigation, the NRC will make every effort-consistent with the public health safety responsibili-ties of the Commission to avoid actions which would clearly be expected to result in the disclosure of my identity to persons subsequently contacted by the NRC.
I understand that, even though the NRC will make every reasonable effort to protect my identity, my identification could be compelled by orders or subpoenas issued by courts of law, hearing boards, or similar legal entities.
In such cases, the basis for granting this promise of confidentiality and any
- g.,
I Other relevant facts will be communicated to the authority ordering the disclosure in an effort to maintain my confidentiality.
I also understand that the NRC will consider me to have waived my right to confidentiality if I take or have taken any action so inconsistent with the grant of confidentiality that the action overrides the purpose behind the confidentiality, such as revealing in public the same infomation given to the NRC or intenticnally providing false information to the NRC. The NRC will attempt to notify me of its intent to revoke confidentiality and provide an opportunity why such action should not be taken.
Other Conditions:
(if any)
I V
ibit 7 (Continued) 2-48
(-
(si have read and fully understand the contents of this agreement.
I agree with its pitvisions.
Date Name and Address Agreed to on behalf of the U.S. Nuclear Regulatory Comission.
i /.b Date Signature, Name and Title
(.
l y, l
(-
1 I
l l
I l
nw 1
A i
'h
2-49
(
(
')
Exhibit 8 v
Guidelines for Administering an Oath or Obtaining an Affimation When the investigator detemines that the affiant is willing to swear or affim to the veracity of the infomation, sworn testimny should be obtained by having the affiant raise his/her right hand. The investigator shculd also raise his/her right hand and say:
"Do you swear" (or " affirm") "that the" (1
" statement given by you,"
(2 "informstion provided by you," or (3
"information you are about to give,"
"is the truth, the whole truth, and nothing but the truth, so help you God?"
An affirmative response validates the oath. Note that the words "so help you God" are omitted in the case of an affirnation.
The choice of the proper phrase within the oath / affirmation is determined by the following circumstances:
I( <I a.
Phrase (1) is used when the affiant provides a written statement.
b.
Phrase (2) is used when the affiant refuses to provide a written statement, but does agree to swear / affirm to the veracity of oral testimony.
c.
Phrase (3) is used when the oath /affimation is administered at the outset of the interview.
When the affiant provides a written statement, the oath or affimation is administered after the affiant has read the statement and made necessary l
corrections, but before the statement is signed. The language in the first l
parenthetical statement of the Format as shown on the follo.ving page is used.
If the interviewee is only willing to provide a signed statement, the language 1
in the second parenthetical statement is used.
If the interviewee refuses to sign the jurat at the end of the statement, the investigator will sign as a witness.
(Sample fomat on the following page) i
\\
V
Exhibit 8 (Continued) 2-50
{
FORMAT I have read the foregoing statement consisting of handwritten / typed pages.
I have made and initialed any necessary corrections and have signed my name in 1.nk in the margin of each page.
I (swear) (declare) that the foregoing statement is true and correct.
Signed on at (date)
(time) 4 i
q Signature and Name (typed or printed)
Subscribed and sworn to before me this day of
, 19 __, at v..
l
<lll>itness, gnat,e and am. (t,,ee o,,,intee)
Title:
v till>
^^
--mm----
-ie i-r
t
^
MMMY j
N, N):_
' GUIDELINES'FOR CONDUCTING INTERVIEWS IIT Procedure 3
3.1 Purpose
'To provide guidance to' ensure interviews are conducted in a unifom, systematic and complete manner.'
3.2 Background
t The. infomation derived from a personnel interview is often directly.
proportional to the skill of the interviewer.. Planning on the part of the
~
interviewer is necessary to conduct the interview systematically.
Predetermined questions concerning suspect areas should be asked of all interviewees.
While intended to' assist the investigator, these guidelines should not limit the team's initiative and judgment. Team members should use their experience or the techniques that provide the most confidence in assuring the team
. achieves its objectives.
The interviews ~are-transcribed by a stenographer to ensure that an accurate mcord of the interview is obtained,'and for the convenience of the incident
/'_
investigation team (IIT). When the team writes its report, an accurate.
l
(
factual record is available to determine the findings and to'make conclusions regarding.the event. The necessity for note taking is minimized during the interview, which also eliminates contradictory and erroneous information that can result from note taking. Team members can give their undivided attention
-to understanding the observations and actions of the ini.erviewee during the event.
t In general,- discussions between the IIT and licensee personnel about routine administrative matters will not be transcribed.
3.3 Guidance 1.
Prior to conducting personnel interviews, the IIT should have been briefed and given an escorted plant tour to obtain an understanding of what had i
occurred and to.obtain a general working knowledge of the plant design and layout.
2.
Personnel interviews should be conducted as soon as possible after the entrance meeting and plant tour to minimize information lost over time from the memories of those involved. High priority should be given to interviewing personnel on duty at the time of the event to learn about the actions they took and the observations they made.
4 3.
Interviews should be scheduled, if possible, with personnel in decreasing order of authority within the staff, beginning with the shift
\\
superintendent and proceeding to 'those less senior. An interview schedule should be prepared for each day. Generally, about 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> should be scheduled for each interview at the plant during an event.
1
l 3-2
.,/
4.
Selection of IIT members that will actively p'articipate as interviewers during the _ interview should be minimized, end based on team member assign-Y3 ments and technical expertise. A minimum of two IIT members should be present at all interviews.
5.
- A lead Ill spokespers'on should be appointed for each interview who is responsible for introducing the interviewee to IIT members, allaying qualms, answering questions about the interview process, providing some
. background on the objective and scope of the IIT investigation, and l
controlling the. interview. The objective should be to establisn an lm element of rapport.
6.
The lead spokesperson should ensure that the stenographers have received the appropriate information regarding personnel names and their employer.
Note: Arrangements for stenographers will be made by the Management AslTstant, Incident Investigation Staff (IIS) from the Office for the Analysis and Evaluation of Operational Data (AEOD). If they are not
- available when the team arrives at the site, contact the Chief IIS or the Director, AEOD.
7.
The lead spokesperson should make an opening statement similar to the following:
q The purpose of the incident investigation team is to establish what happened, to identify the probable causes, and to provide appropriate feedback to the industry regarding the lessons learned from the incident.
The reason for conducting interviews is to ob*.ain information regarding the actions and observations of personnel who were directly involved with the event. If you desire, you may select and invite any individual to be 77 present during the interview as your representative.
These interviews are transcribed in order. to aid the team in developing a factual record and as a convenience to minimize the amount of note taking.
At the conclusion of the interview, it will be transcribed and made available to you for review. You will have the opportunity to make corrections regarding where you feel that something was transcribed incorrectly or make clarifications to your statements which were what you said, but not what you meant. The corrections and clarifications will be included as part of the transcript. At the conclusion of the investiga-tion and the issuance of the team's report, the transcript will be made publicly available in the NRC's public document room. At that time, if requested, a copy of your transcript will be provided to you.
If for any faason you want to go off the record or take a break, let us know. Do you have any questions regarding the investigation or interview process?
8.
The formal interview should begin by having the interviewers identify
'themselves and place on record the date and time the interview comenced.
The interviewer should establish the identity cf the interviewee. The interviewee should state his/her employer, job title, and provide a brief O
employment history. Third parties should attend interviews only at the d
request of the interviewee.
If a third party is present during the interview, the interviewer should establish on the record at the beginning of the interview that the presence of the third party was requested by the
~
3-3 7
(M interviewee as his/her representative, and indicate the person's name, job
/
. title, and association with the interviewee.
9..
Interviewees will nomally be permitted at their request to have personal counsel or another 1r.dividual accompany them during the interview. Other-wise, third. parties. such as licensee management, company counsel, and union stewards, will not nomally be pennitted to attend the interviews.
-The interviewee may consult with counsel during the interview. Counsel's participation iri tne interview will be generally limited to advising his client and asking brief clarifying questions to ensure that his client has 1
understood the questions asked by the IIT.
If the counsel or other i
individual also represents or is to accompany another person being interviewcd, the IIT will-nonna11y permit the attendance of that person if the IIT is satisfied that attendance will' not appreciably compromise its investigation.
The IIT normally will not permit tape recording of the interview by the interviewee since the interview will be transcribed and the interviewee will be provided a copy of the transcript, if requested.
F If the policy regarding the rights of interviewees is unclear and additional' legal advice is necessary or desired, the team leader should contact the Assistant General Counsel for Enforcement in OGC.
4 q 10. Tha interviewer should allow the interviewee to tell what happened in his
[- \\
or her own way, starting from a time well before the event, but at a point V
well defined in the interviewee's mind (e.g., start of shift, lunch bretk).
- 11..During the initial narration, the interviewee should be allowed to tell what happened with little or no interruptions by the interviewer. The interviewer's ability to be a good listener and to keep the interviewee talkine is essential.
- 12. Note taking during the interview by NRC personnel should be minimal and l
unobtrusive, and should cease if it is distracting the interviewee.
i
- 13. Followup questions should be kept simple; avoid jargon or terminology that could be foreign to the interviewee. Be objective. Avoid questions answerable with a simple "yes" or "no."
Questions such as "is it fair to say..." or "would you agree that..." are useful ways to connunicate that the interviewer understands what the interviewee said. "Can you tell me anything more?" is a good question to ask frequently for subsequent explorations.
1 14.- Explanatory sketches, diagrams, or photographs are valuable supplements to l
the interviewee's statement. They should not be construed, however, as substitutes for the narrative statement. When a document is presented and discussed during the interview, the document should ue referenced and entered into the transcript as an exhibit, assigned a number, and provided O
to the sten 9tapher to be included as part of the transcript.
3-4 s"*"W
(
)15. At the conclusion of the formal interview, the interviewer should ask the interviewee on the record if there is any other information the x '-
interviewee wishes to share with the IIT that has not been specifically covered during the interview.
- 16. The lead spokesperson should provide ti,e phone number and location where he/she can be reached should the interviewee recall additional information to share with the IIT.
- 17. A copy of the general guidelines, " Review and Availability of Transcripts," is to be provided to all interviewees at the end of each interview (Exhibit 1).
- 18. The transcripts are controlled and handled according to Exhibit 2, Handling Transcripts. A copy of this exhibit must be given to the NRC custodian for the transcripts.
v m.
.-w
-e-
--r m
Fm '
[g.
3-5
.j g m
~
. -()'.
Exhibit I
~
. Guidelines for Review and Availeb1111.y of Transcripts
^
The: Incident Investigation Team.(IIT) has had interviews and meetings tran-7
- scribed to assist the team in its investigation.
Interviews should be tran-scribed overnight and, in general, be available for review the following day.
. Individuals wishing.to review their transcripts shc,uld bring proper identifica-tion with them. Transcripts of interviews and meetings are available for a
mview under the following gui.delines:
(1) During the team's investigation, a copy of the transcript of personal i
interviews will be made available for review only to individuals who were
_ interviewed. -In the case of joint interviews, each person who was interviewed may examine that transcript. Individuals my read only their transcript, and may consult with personal counsel while reviewing the transcript. No copies of the transcript are to be made.
- (2)
Individuals may make corrections to their answers. Corrections should be made on errata sheets which will be attached to the transcript (see the form attached) rather than on the transcript itself.
If anyone wishes to
- speak further with the IIT, the tean will be available for further inter-views. These interviews will also be-transcribed.
)
(3) After the conclusion of the investigation, each individual interviewed.
. upon request, will be given a copy of the transcript of his interview for
. his personal retention and use.
(4) 'After those interviewed receive a copy of their transcripts, the transcripts will be transmitted to NRC's Public Document Rooms where it will be available to the public.
l'
'(5) Transcripts of meetings between the IIT and the licensee will be available to NRC personnel (including the Region) and licensee personnel for review.
The licensee may make corrections which will be included with the tran-
. script. Corrections should be made'on the errata sheets that will be provided rather than on the transcript itself.
(6) Copies of the meeting transcripts will be provided to the licensee for its l
retention.after the IIT has concluded its investigation. The transcripts L
will be made available to the public unless the licensee has made a request to protect proprietary information in the transcripts in accord-ance with NRC regulations.
g-1 O
f
,--v
.-+e 6---.,+*r.
-.-+.oww-.---.w...--
e-c.
J e
- e.
Exhibit 1 (Continu:d) 3-6
.-~
jD}RLCTIONSFORMAKINGCORRECTIONS
~1f you have any corrections that you wish to make on your transcript, please do i ro on the following page in the following fashion:
Indicate the page of the correction, the line number, then the change to be made and the reason for making the change. Date and sign all correction p6ges that correspond with your transcript.
If you have no correctioris or clarifications, please state this on the following page and date and sign the correction page.
f\\()
L e
W 6
O l
l l
'; Exhibit I~(Continued) 3 f
' f~$.;
4'j ?'
ADDENDUM TO INTERVIEW OF (Print Identity of Interviewee)
Page-
.Line Correction and Reason for Correction i
I 4
4 i
+
t f
s -\\
J i
i f
1 P
4 i
+
A Page Date Signature
3-8 1
Exhibit 2 HANDLING TRANSCRIPTS JPurpose: To est'ablish guidelines for the Incident Investigation Team (IIT) regarding the proper administrative handling of transcripts.
Procedure General Immediately upon the establishment of an IIT, the IIS shall contact the Project Officer from the Atomic Safety and Licensing Board Papel (ASLBP) to procure stenographer service. Two. stenographers are to be requested in order to provide overnight turnaround from tne reporting service for transcripts ~and in the event that the team leader desires to use parallel team interviews. The location and schedule for the first interviews should be provided to the contractor. '(See Administrative Procedure 3.)
Procedures - Specific 1.-
The~ IIS will notify the Region (resident inspector) to make arrangements with the licensee to supply two rooms for conducting the interviews.
- 4 2.
Interviews conducted each day should be transcribed overnight and five*
[)
copies of the transcribed interviews will be made. The contractor will V
send the original transcript and two copies to the' Chief of the IIS for reference and the other three copies will be available to the IIT at the site the next day. One of these copies will be made available for review to those individuals interviewed. Errata sheets resulting from this review will be copied and copies attached to each transcript. The original errata sheets will be sent to the IIS to be attached to the transcripts sent to neadquar'ars.
a 3.
An individual should be requested from the regional office (or alterna-tively, the secretary in the resident's office) to maintain control of the transcripts-(referred to as the custodian). This control consists of (a) assuring that unauthorized individuals do not gain access to the tran-scripts, (b) contacting (each interviewee to schedule an appointment toc) checking review the transcript, in the interviews and assuring that they are reviewed individually and that copying does not take place, (d) making sure that the transcripts remain in the roon where they are being reviewed, (e) maintaining control of errata sheets and assuring they are properly completed and attached to the transcript and distributed, and (f) when authorized, transmitting the transcripts to the interviewee at the completion of the investigation in
- response to his/her request.
\\
The number of copies may vary depending on the NRC contract.
I
- m..
_.m,...m.. _,, _. _, _ ~ _ _,, -.. _.,. -.,. _ _ _ _ _ _..
..m
=
Exhitiit2'(Centinu-d) 3-9 n
~ (V) 4.
A list of completed interviews should be compiled for the IIT by the custodian for the transcripts.
Each transcript should be identified by a number, name of interviewee, job title, date and time of interview.
5.
After the IIT report has been presented to the Commission, all transcripts will;be transferred to the IIS for proper disposition.
a.
All copies,are to have errata sheets attached to them.
of ecch transcript is to be transmitted to the Public Document A copy (PDR), the local PDR, and to the Document Control Room, b.
Room c.
One copy is to be sent to the Project Officer in ASLBP for the purpose of determining reporting service costs. This copy will be returned to the IIS and, along with the original transcripts, will be placed in the IIS file for future reference.
6.
Specific Guidance for the Custodian:
a.
Ensure that transcripts of individual interviews are checked out only by the individual who was interviewed (as identified on the first
-page of-the transcript).
In the case of joint interviews, each i
person who was jointly interviewed may examine that transcript.
b.
Be aware that transcripts of meetings between the licensee and NRC h\\
personnel may be checked out by either NRC or licensee personnel.
o c.
Keep a sign-out sheet for the transcripts. Log in the time checked out and the time returned for each transcript, the title of the transcript (for example, " Smith Interview," "6-15-85 Meeting"), and the person who checked the transcript out.
d.
Ask for identification of persons checking out the transcript, particularly for persons wishing to see the individual interviews.
e.
Ensure that the individual has been provided a copy of the general guidelines " Review and Availability of Transcripts," which includes instructions for making corrections of transcripts (Exhibit 1). Also provide an errata sheet and additional sheets as requested.
f.
If there are no corrections provided by the individual, the errata sheet should state this.
g.
Collect any missing errata sheets and make sure they are signed and dated.
h.
Do not permit photocopying or retention of the transcript until its l
release is authorized by the IIT.
i l
1.
Copy and attach all errata sheets to the transcript copy that was made available for review to the individual.
If an interviewee chooses not to review his transcript, so note on the errata sheet.
i
~.
3dEWOMY
.g
?M GUIDELINES FOR d
i
. THE TREATMENT OF QUARANTINED EQUIPMENT A2 IIT Procedure 4 4.1'
Purpose:
f
- To provide guidance for equipment to be quarantined and related troubleshooting action plans curing an Incident Investigation Team (IIT) investigation.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX lX-X
'X' Attention X
X X
X At all times,- the licensee is responsible for quarantined equipment X
45 X.
- and can take action involving this equipment it deems necessary to:
X X-X X
o-achieve or maintain safe plant conditions, X
X
'o prevent further equipment degradation, or X
X' o
test or inspect as required by the plant's Technical X
X
_-Specifications X
X~
X X
To the maximum degree _possible, these actions should be coordinated with X the team leader in advaace or notification made as soon as practical.
X
.X X
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX v :4.2. Background The objective of an IIT investigation is to collect, analyze and document factual information and from it determine the probable causes, conditions and circumstances pertaining to the event. To learn how equipment failed or performed in an anomalous manner during an event, the IIT must minimize the potential that the equipment could be manipulated such that important infonnation concerning its performance during the event could be lost. Thus, the Regional Administrator quarantines the equipment in its "as-found" condition, usually tnrough a Confirmatory Action Letter (CAL). Then the licensee develops a detailed troubleshooting action plan for systematic 4
l inspecting and troubleshooting the equipment in order to idantify the probable causes for its failure or observed perfon.,ance. After the probable cause(s) of failure of a particular component or piece of equipment is determined, the i
equipment is released from quarantine.
The CAL confirms the licensee's intention / plans, among other things, that any equipment that may have malfunctioned during the event be preserved, Exce)t as l
required for safety, in its present condition. Thus, the licensee is to 1old in abeyance all work in progress or that is planned for the equipment. The IIT leade-is authorized to define and revise the quarantined equipment list (QEL),
and to approve testing or troubleshooting of the equipment, j
4.3 Quarantined Equipment List (OEL)
The QEL should be limited to that equipment that was significantly involved in the event. For example, only that equipment that failed or malfunctioned during the event and had an impact on the sequence of events should 'be 4
-.--...--.----,-,s or
4' 4-2 7 T ncluded..(Exhibit I contains a sample QEL.) Equipment can be added or i
p hdeleted from the list as the -investigation progresses. Equipment remains on the list until the team leader determines that the probable causes of failure
. have been identified or that its. performance was not a significant contributor to the event. Quarantining equipment can result in a significant disruption to the licensee's activities, so the team should minimize the impact to the maximum degree possible.
The IIT and licensee. representatives should reach a comon understanding about
- the scope of the QEL, why each piece of equipment on the initial list is there,
- and what the boundaries of the quarantine are. Boundcries should include
- relevant components and/or systems that may have caused or contributed to the
- failure or observed perfomance of the equipment. For example, instrumentation and control, power supplies, and cabling necessary to the operation of the equipment need to be defined as to whether they are in or out of the quarantined boundary. Again, discretion and judgment must be exercised to
- minimize impact on the licensee's activities.
As noted previously, the licensee on its own authority can take action as appropriate (1) to achieve or maintain the facility in a safe, secure condition, (2) to prevent further equipment degradation or damage, or (3) for testing or inspection activities required by the plant's Technical Specifications.
If there is a conflict about an item on the QEL that the IIT believes is vital to its investigation, the team leader and the licensee should
-agree on a procedure to minimize the amount of key information that could be A lost. If the conflict cannot be resolved to the satisfaction of the team leader, he should infom the EDO of the problem and obtain guidance for its resolution.- For example, both diesel generators malfunctioned during an event
. and had to be placed on the quarantine list. Technical Specifications require one diesel generator to be made operable within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. The IIT leader should review procedures developed by the licensee to meet the limiting i
condition for operation as well as to minimize the amount of key infomation that could be lost.
4.4 Quarantined Equipment List Guidelines 1.
The QEL should be compiled and maintained by the licensee, and reviewed W
and approved by the IIT.
l 2.
The QEL is subject to multiple revisions. The current QEL should contain its revision number, date, and the changes made to it from the previous version.
l.
3.
The QEL and its revisions should receive prompt and wide distribution includino the IIT, NRC Offices, the Region, and licensee organizations,
~
e.g., as part of the Preliminary Notification (PN) status report.
4.
Equipment on the QEL should be clearly identified and secured in the plant (roped-off, tagged out, labeled, etc.) to the extent practicable. A licensee-designated individual for the particular equipment should be identified such that he/she can be contacted when access to the area / equipment is necessary and coordinate with the IIT.
4-3 b 4.5 Guidance for Developing Troubleshootino Action Plans-O Estab1lishing treibleshooting a:: tion ' plans for quarantir.ed equipment is
'necessary ir, order to provide a. process by which the probable causes of the conditions observed and equipment malfunctions can be ascertained. It is important.that the troubleshooting activity on the equipment does not
- inadvertently result in loss of information necessary to confirm postulated
~ causes of. equipment rialfunctions. - Action plans ensure that the troubleshooting
'is systematic, controlled and well-documented, and that adequate records on the "as-found". condition of malfunctioned equipment are maintained.
'A proven. method of minimizing the time spent in reviewing action plans, yet ensuring their completeness, is for the IIT and licensee to agree on generic guidance that will be part of each action plan and included in the troubleshooting activities. From the generic action plan, specific action
- plans (one for each piece of equipment quarantined) shoulo be developed by the licensee. When the IIT receives a specific action plan for review, it can focus on the details for the equipment under investigation.
4.6 Guidelines 1.
For each item on the QEL, an action plan should be developed by the licensee for investigative or troubleshooting work and approved by the IIT leader prior to implementation.
(Note:
In order to minimize delays, if possible, the IIT should complete its review of all troubleshootir:g action plans prior to leaving the site.)
2.
The action plan must clearly document the scope, affected equipment, and
.the objectives of the troubleshooting activity.
It should be a self-contained document that provides a definitive basis for the trouble-shooting work.
In general, the IIT may review maintenance work orders (MW0s) for information, but not formally approve them for troubleshooting.
Existing plant surveillance testing procedures, functional test procedures, or maintenance procedures can be modified or incorporated into the action plan.
L
'3.
The action plan should document all as-found conditions, such as any missing, loose or damaged components, and note their positions (open, closed, up, down, knob settings, switch positions, setpoints etc.), and any abnormal environmental conditions the operation of cooling devices, water leaks, oil leaks, locse fittings, cracks, evidence of overheating or l
water damage, cleanliness, bent tubing fluid levels, jumpers, lifted i
wires, etc. Whenever possible, photographs should be used to document I,
as-found conditions. When necessary, samples of fluids or their residue should be retained for further analysis.
l 4.
A cognizant licensee engineer knowledgeable in the design and performance requirements for the equipment under consideration should be identified to be the point of contact and be responsible for each action plan.
i
I 1
4-4 A) 5.
- The action plan should include or require a review of all known tv information and data defining conditions existing prior to, during, and af.ter the event. This information should include maintenance,
- surveillance, and tut histories and any changes in design or in the method of operating the equipment and/or system. Significant findings from.this review should be included in the action plan and used in formulating hypotheses for the probable causes of equipment and/or system anomalies.
6.
The action plan should include, if possible, a requirement to test the equipment during conditions under which the system, train or component failed to operate properly. Such tests are extremely desirable when the
' causes of the failure are not obvious. The IIT should ensure that the test procedures. duplicate, when practicable, the component conditions that existed during the event. When actual conditions cannot be reproduced.
simulated conditions may suffice if their limitations on testing results are specified.
7.
The action plan should indicate the apparent cause(s) of the equipment malfunction and include precautions against the destruction of material evidence that woule substantiate the apparent or any other cause.
8.
The action plan should address the degree of participation by vendor representatives. Vendor representatives should at least be contacted to
- discuss the performance of the equipment. Their participation should be f
encouraged if appropriate licensee expertise is not available. Vendor representatives are also expected to follow the action plan and requirements of the MWO.
9.
The action plan should list the sequence of troubleshooting activities as procedures.
If the sequence can be determined prior to.the-activity being performed, that sequenca should be spet(fied, with a check-off for each step.
If a specific sequence cannot te determined prior to the activity, a general sequence should be identified, with specific steps documented as they are performed.
- 10. The sequence of troubleshooting activities should include hold points to enable observation and photographic documentation of conditions found.
NRC regional staff will normally provide oversight during the trouble-J shooting activities.
j P
- 11. Repairs or corrective maintenance to conipment should not be part of the action plan (outside the scope of the IIT). These aspects will be handled separately by the licensee and the NRC following the troubleshooting process.
12.- The action plan should specify that when conditions t,ther than what might have been expected based on the developed hypothesis (ses) are noted during
/g troubleshooting, work should cease and appropriate licensee and NRC personnel consulted prior to resuming.
a l
we-,w,-,r y
,---w
--._we-,-__-.y
-,_ _, -._--_ - -,m,,
.--_,,-..,...,_._,--,--,--_.--r,
-~---------_-._,.-.mw-
4-5
- 13. The action plan should state that all replaced components / equipment should
~
x
-be retained for subsequent review and examination, and that complete 1
traceability should be maintained. Damaged equipment should not be
'x.) -
discarded or shipped offcite without prior t<:am leader approval. The IIT may require that the failed components be exemined by an independent laboratory.
- 14. Completed action plans and the schedule for the implementation of
. troubleshooting activities should be reviewed by the IIT before completing the-initial onsite phase of the investigation. A coordinated approach should be established so that, to the degree possible, the Team's
,1 activities do not unnecessarily delay implementation of licensee recovery actions.
- 15. The licensee should advise the IIT/NRC Resident Inspector as soon as practical of work plans and schedules so that arrangements could be made with the regional office to have NRC staff available to observe troubleshooting activities.
I
- 16. The licensee should notify the IIT when the probable cause of each equipment malfunction / failure has been identified. Agreement should be reached with the licensee on the extent, nature, and schedule of the troubleshooting documentation.
- 17. Repairs and corrective actions on the quarantined equipment should not proceed until the IIT has concurred in the probable cause determination
-and the piece of equipment has been removed from the QEL.
Q 18. Generic guidance for the investigation of troubleshocting equipment is contained in Exhibit 2.
Several example action plans are provided in Exhibit 3.
The generic guidance and example action plans can serve to help guide the 1fcensee's activities and should be provided for his/her information and consideration.
i l
~
a
4-6 Revision 1 Y7 October 10, 1985' ym Exhibit 1
- l 1.
'V Sample Quarantined Equipment List The. licensee recomunends 'th'at the following items remain quarantined:
-1.
Main Feed Pump Turbine and Controls c2..SteamandFeedRuptureControlSystem(SFRCS)andAssociatedInstrument
. Channels.
3..' Auxiliary Feed Pump Turbines cnd Controls L4.. Main Steam Isolation Valve Including Controls, Actuating Circuits, r
4 Pneumatic Supplies 5.
Start-up Feed Valve SP-7A, and Controls 6.
Source' Range Instrument Channels 7.
TurbineBypassValve(TBV)SP-13A2-andanyothercomponentsindicating water hammer damage.-
[]
Traps and drains associated #2 TBV header: MS 2575, MS 737, MS 739, ST 3, Q!'
ST 3A 8.
Power Operated Relief Valve and its controls and actuation system g
9.
Main Steam Safety Valves and Atmospheric Vent Valves
- 11. Main Steam Valve MS 106 and Controls
- 12. Service Water Valve SW 502 and Controls on Auxiliary Feed Valves Alternate
~
Supply This item was released by the IIT:
- 1.
Safety Parameter Display System (SPDS)
This item was added by the IIT:
1.
Service Water Valve and Controls on Auxiliary Feedwater Alternate Supply It Lis agreed that no work will be done in the proximity of, or on, this equipment.
O
S
' Exhibit 1 (Continued) 4-7 The_ licensee agreed to complete a walkdown outside the containment building of
- the' main steam system by appropriate personnel to identify any additional damage that may have been caused by water hamer.
e b
e O
4 l
i I
w
.e-n.---.wver,--,-----
.,,,,---,w,
,e,,,, _ _
g---
,,_n,,,,,
m-,-,------,,--,-es,mn,,m,a-,
4-8
-.-[]j Exhibit 2 Generic Guidelines for Troubleshooting the Probable Causes for Equipment Anomalies
- For each item on' the' Quarantined Equipment List, an action plan should be
' developed by the licensee for investigative or troubleshooting work which p(rovides the basis for the Maintenance Work Order (MWO). lead and/or support) deve Licensee personnel action plan and have knowledge of the design criteria of the specific area being considered. Vendor engineering support will be utilized as necessary to accomplish this requirement..When used, vendor assistance should be documented.
All troubleshooting activities should be preceded by event evaluation and analysis to determine the hypothetical and probable causes of failure or abnormal operation. Conduct the analysis and evaluation as follows:
a.
Collect and analyze known infomation and operational data for conditions prior to, during, and after the event.
b.
Review maintenance, surveillance and testing histories, c..-
Develop a summary of data including a and b above, that supports any y
proposed probable cause.of failure or abnomal operation.
d.
~ Conduct a change analysis (i.e., what has changed since the last known successful operation of the system or equipment).
- e.
Based on items a-d, develop primary and alternate hypothesis (ses) for the probable cause of the problem.
f.
Develop plans for testing the probable causes and hypothesis (i.e.,
checks, verifications, inspections, troubleshooting,etc.).
In developing inspection and troubleshooting plans, take care that the less likely causes/ hypothesis (ses) remain testable.
g.
When planning troubleshooting, try to simulate as closely as practical the actual conditions under which the system or component failed to operate properly during the event.
Plant and personnel safety take precedence over all other considerations.
After notifying the IIT leader, licensee personnel can temporarily or per-manently remove equipment from the quarantined equipment list to (1) achieve e
or maintain safe plant conditions, (2) prevent further equipment degradation, or (3) test or inspect af required by the plant's Technical Specificatior.s.
It is very important that the investigation not result in the loss of any information caused by disturbances to components or systems.
Investigations need to be conducted in a logical, well thought-out, and documented manner.
e--, -., --,.,. - -,
,..---,--,,--,----,nm,-_,,,,,.,,-,,,.---,nn,-----,-_
,,-c,. - -,---- ---
p Exhibit _2 (Continu:d) 4-9
?~"s To avoid the!1oss of.information and to assure the capture of reliable
-(V) tion'.totherequirementsofexistingplantprocedures,wheninitiatingandinformation, Tice'n 1
t mplementing an MWO.
i 1.-
Review all action plans for troubleshooting and investigative work with IIT/NRC personnel prior to implementation.
)
- 2.
. Ensure that MW0s r' elating to the investigation are coordinated with the quality assurance department.
3.
Document troubleshooting and repair on separate MW0s.
4.
Have W0s approved by the action plan cognizant engineer and reviewed by Quality Control and plant management prior to their implementation.
It is the cognizant engineer's responsibility to assure that the investigative actions are appropriate, sufficient, properly defined, documented, and
- that data is preserved.
5.
Assure that only current drawings and controlled vendor manuals are used.
6.
Consider the need for vendor representatives. -Vendor representatives should be used to assist in troubleshooting if appropriate expertise is not available in-house. The representatives will need to be given
--specific guidance for what they are and are not to do. Vendor representatives must follow the guidelines of this memorandum and
[s^
requirements of the MWO.
\\
7.
Ensure that the MWO clearly documents the scope, affected equipment, and the desired objective of the investigative activity.
8.
Document the sequence of activity on the MWO or specify procedures in the MWO.
If the sequence can be determined prior to the activity being perfonned, define that sequence and provide a checkoff for each step.
If the desired sequence cannot be determined prior to the activity, as a minimum, define the fundamental sequence to be taken and document each specific step as it is performed.
9.
Document on the MWO all as-found conditions. Visually inspect and t
document any missing, loose or damaged components, note positions (open, closed, up, down, knob settinos, switch positions, setpoints, etc.),
abnormal environmental conditions, operation of cooling devices, water
~
leaks, oil leaks, loose fittings, cracks, evidence of overheating or water damage, cleanliness, bent tubing, fluid levels, jumpers, lifted wires, etc. - Describe the overall condition or appearance. Whenever possible, use photographs to document as-found conditions. When considereo necessary, retain a sample of fluids or their residue for further analysis.
- 10. When conditions other than what might have been expected based on the developed hypothesis (ses) for the probable cause of the equipment mal-
/6 function are noted during the investigation, stop work and notify the Action Item Lead Individual. Document the discrepancy. The Lead Indi-vidual must sign-off on the discrepancy before the investigation continues.
~g.
. Exhibit 2(Continueif) 4-10
('N 11. ~ Document the results of the investigation on the MWO.
V) 12. Prior to starting any repair activities, ensure that the licensee
(
~
- cognizant engineer documents that all. investigations have been properly completed.
- 13. Ensure that no equipment is to be shipped off site without prior approval of the IIT.
Note:.
In all cases, follow applicable procedures. The requirements
- of this memorandum must be communicated to craft personnel to avoid any confusion or misunderstandings during this investigative period.
- 14. ' Retain all failed or removed components / equipment for ongoing review and examination. Maintain complete traceability.
The IIT/NRC shall be notified when the probable cause of the malfunction /
failure has been made deterinined. As soon as practical, the results of the troubleshooting process, probable cause determinations and justification will be presented to the IIT/NRC (e.g., next day in a meeting).
~
. The NRC shall be advised as soon as practicel of plans and schedules for corrective work and before the work is performed.
Note:
Any communications with the NRC personnel will be coordinated through O
the cognizant licensee engineer.
v i
i G
--4 e.-
wrv,o,
+w,,--y,-m--,m..,e.e-,-,------,----w--, - - -. - -
,-e-.--
,--+--,,im--
,,--a---
,,.3.-
g-----,.w---
v.-c y-- - - - - --.-s y--------.-v.w.----e
7,.
~
4.
4 11
' '#N-Exhibit 3 i
i O
Example Action P1ans ACTION PLAN i
- 10 j
TITLE:
REVIEW OF THE OPERATION OF THE FORY r
APPR.
CHAIRMAN FOR REV
.DATE REASON FOR REVISION BY TASK PORCE IMPL.
0 6/21/85
. Initial Issue See Rei. O for Approvals
~
I-y fa -
1 7/2/85 Revised text and action plan to update.
g g, y
Revised text and action plan to address
/
2-7/8/85 control circuits T. Isley L
l l
O e
O 1
i l
,,r
_ _ _ _ ~.
Exhibit 3 (C:ntinurd) 4-12 a
7 fN TITIZi REVIEW OF T E OPERATION OF THE PORV y -
REPORT ST:
Tom'Isley PLAN NO:
10 DATE PRE?ARED: 07/08/85 PAGE 1
of 5
This report has been preparei in accordance with the " Guidelines to Follow When Troubleshooting or Performing Investigative Actions into the Root Causes Surrounding the June 9,1985 Reactor Trip", Rev. 4.
I.
INTRODUCTORY STATEMENT:
This report describes the way the PORV responded during the transient on 6/9/85 and identifies analysis and actions needed to identify root cause(s).
II. SIR 9 FART OF DATA:
During the transient on 6/9/85, the PORV cycled three (3) times. The first time the PORV opened for 3 seconds and then closed at the proper _ setpoint. The second time the PORY (,pened at the proper setpoint for 3 seconds and then closed approximately 25 psi below the
~
required setpoint. The third time the valve opened at the proper The setpoint but did not appear to resent at the proper pressure.
operator observed that pressure was decreasing and the PORY indicated A
I closed. Because the spray valve was fully opened (by placing the l
control switch in "open), the operator thought that was causing the pressure decrease. He returned the spray valve to Auto and then closed the PORV block valve as a precautionary measure. After the pressure decrease had slowed, the operator reopened the block valve L
while observing system pressure. Be decided that the PORV was closed and was holding reactor coolant pressure.
e It should be noted the PORV block valve stoke time is approximately nine seconds. The acoustical monitor indicated that flow stopped in approximately seven seconds after the block valve started to move to l
l the close position. The exact time at which flow stopped is uncer-f tain because the acoustical monitors are not designed to indicate l
accurately at low flow rates. Therefore, it cannot be positively identified if the PORY reset (at approximately 300 psi below the required setpoint) or the block valve closed which stopped the flow through the PORV.
Reviewing the previous operations of the PORY shows a total of 91 hot cycles and 17 cold prior to 6/9/85. Adding the 3 hot cycles gives a l
total of 94 hot and 17 cold, as compared te an allowable number of l
440 hot and 15 cold cycles. It has also been determined that the tanperature of the loop seal was 469'F which is greater than the regnired 400*F (ninimus), therefore, no piping analysis is required I
as a result of the 6/9/85 PORV actuation.
1
(
l
Exhibit 3 (C ntinued) 4-13 Pas 2 2 of 5 i
'III. NAINTENANG AND SWVEILLANCE/Tb5T EISTORY:
_ p)
'12-14-76 h PORY was disassembled, inspected, and the seating
'(v surfaced lapped (HWO 2161). The valve had lifted 8 times
'since it was installed.
08-01-77 The PORY failed to open. Replaced power fuses (NWO 77-L592).
e i
09-05 The.PORV was disassembled, inspected, and seaties surfaces lapped (NWO 77-1903). The valve had lifted 14 times since last maintenance.
09-24-77 The PORV fail'ed open during a loss of feedwater accident.
h valve was disassembled and the pilot valve was found stuck open. The pilot valve stem was replaced and the nozzle guide was cleaned. When the valve was reassembled j
and tested, the valve again failed open on the sixth cycle.
h valve was again, disassembled and inspected. h pilot valve stem was machined to correct the pilot stem-nozzle guide clearance, and the stroke of the pilot valve was adjusted. The valve was cycled 12 times at reduced pres-sure and once at 2200 psig with no problems.
(Reportable Occurrence NP-32-77-16, HWO 77-2120 and MWO 77-2256.)
01-18-79 Because the PORV was leaking, it was disassembled and inspected. The disc, seat, and pilot valve were found to have minor cutting. Tney were lapped and.the valve was reassembled (MWO 79-1307); The valve had lifted 67 times p}
since last maintenance.
(G 04-19-79 h PORY actuating linkage was checked for proper operation and proper supply voltage to the solenoid coil was veri-fied. No probleur found (MWO 79-1978).
05-17-79 h setpoints-for the PORV were changed to open er 2400 psig and close at 2350 psig' (FCR 79-169).
10-29-79 Because the PORV was leaking, it was disassembled and inspected., The. valve disc and pilot disc were lapped and the valve was reassembled (MWO 79-3433). Tbc valve had lifted 2 times since last maintenance.
03-24-82 Becauce the PORV was leaking, the valve was disassembled and repaired (MWO 81-366::). No lifts since last maintenance.
i.
09-01-82 h PORV was stroked per PT 5164.02. No problema found.
09-06-83 h setpoints for the PORV were changed to open at 2425 pais and close at 2375 psig (TCR 79-348).
f 09-14-83 h bistable setpoints were checked by ST 5040.02 and found to be acceptable.
I l
f
Exbibit'3 (Continued)~
4-14 P:32 3 et 5
. ['N 12-28-84 The bistable'setpoint.s were checked by ST 5040.02 and found 3
)
to be acceptable, v.
- Maintenance and TestJummary The majority of the maintenance was to correct for minor leakage.
The valve failed open one time, was repaired, and had operated
,t
' properly price to June 9.1985. The routine testing has not found any prob,less with the PORV.
Channe Analysis Since the FORV was last operated on September 1,1982, the only change was to the bistable setpoints. Since the bistable. functioned 3
properly and the setpoints have been verified twice since they were changed, this did not have any effect on the operation of the PORV.
There have been no other changes since the last successful operation.
Failure Hypotheses Sususary A discussion with B&W about the way the PORV operated, produced several possible causes.
During the first two lifts of the PORV, the loop seal could have 1.
emptied which would have allowed the valve to pass only steam The hot steam could have caused the disc during the third lift.
/7..
to expand more rapidly than the valve body causing the disc to
-( j After the valve temperatures had equalized, the disc stick.
Subsequent Toledo Edison calcu-would free up and then resent.
3 lations have shown that the loop seal would have been emptied during the first lift of the PORV.
The linkage for the pilot valve could have broken allowing 2.
closed indication,but the pilgt valve,would still be open, keeping the PORV open.
i One of the solenoid coil guides could have broken causing the l
3.
This has happened on a similar valve by a valve to stay open.
different manufacturer.
Possible corrosion or boric acid buildup on the solenoid coil 4.
linkage causing the linkage to stick.
A piece of foreign material inside the valve caused the disc or 5
pilot valve to 63rk open.
The possibility exists that pressurizer level was high enough to 6.
This has been rejected as a
.put water through the valve.
possible cause for the failure because the valves tested by EPRI all worked properly when tested with water.
O
,.w-,
. + ~.. _., -.,.
Exhibit 3 (C:ntinued) 4-15 P 32 4 ef 5
+
The Crosby Valve and Gage Co.'was contacted and they were unable to
_[Q
_q) provide any additional'information about possible failure modes for the FORV. They reminded us that their valve worked very, well in all of the testing done by EPRI.
We have reviewed the EPRI test data to determine if the testing done would provide any information. The testing done by EPRI used a similar Crosby valve with a 13/8" bore while ours has a 14" bore.
They had'some problems initially with the pilot valve bellows crack-
' ing or being improperly machined but the valve functioned properly after these problems were corrected. Previous maintenance has detected no problems with the bellows in the valve at Davis-Besse.
The EPRI test demonstrated that the tested valve closed in 0.1 to 0.2 seconds.-
The EPRI test set up did have a loop seal. In one test, the condi-
+t
~
tions were very close to the conditions experienced on June 9,1985 insediately prior-to the first lift of the valve. In the EPRI test the valve closed properly, however, they only did one cycle while we experienced multiple cycles.
Our review of the NPRDS data since TNI 2 found a PORV failed open at another utility one time. The valve that failed is a different design and that failure is not believed to be related to the failure i
l we experienced.
1 Our review of " Nuclear Power Experience" for PWR's found several PORV failures due to' seat leakage ard 6 times that a PORY failed open or e
could have failed open at another power plant.
g
~
Oconee 3 - PORV failed open due to heat expansion, boric acid o
buildup, solenoid lever rubbing, and bent spring bracket.
^
Connecticut Tankee - PORV failed open due to dirty contacts in o
the control circuit.
North Anna 2 - PORV failed open when returned to service after I
o l
maintenance due to improper assemb1y.
" Palisades - During system pressurizatica, the PORV was found to o
have excessive leakage. This was caused by the pilot valve being held open by the solenoid plunger because the plur.ger spring had slipped due to a loose spring guide.
Ginna - The PORV failed open due to a restriction on the air o
discharge from the solenoid valve. This restriction prevented the solenoid valve from resetting when power was removed.
TMI I - An inspection of the internals of the PORV found corrosion o
buildup that could have caused the valve to fail open.
The failures identified do not appear to have anything that would indicate a common type of failure.
(
,,,m--
~r
,,,n, - -. - - - - -,,-- _,, _,., -,,,,, _ _, _, _ _,,,,
Exhibit'3 (Continued) 4-16 Pes 2 5 of 5 The PORV was disassembled on 7/6/85 and inspected by the Crosby field representative. 1his inspection failed to show any problems that could f5 have caused the valve to remain open after receiving a closed signal.
As
]
)
a result of.the inspection, Crosby has recommended that the following
\\~/
2 additional testing be performed.
1.
- Check the control circuits to verify proper operation.
Reinstall the valve and cycle the valve several times at reduced 2.
pressure (approx. 600 psi) and then again at full pressure.
IV. EYP0 THESES:
The PORY stuck open due to differential expansion of the disc 1.
and body.
The valve mechanically malfunctioned causing it to not close
-2.
during the transient.
The solenoid coil linkage could be broken or have corrosion 3.-
buildup causing faulty operation.,
t A piece of foreign material caused the disc or pilot valve to 4.
stick.
A control circuit malfunction caused the PORV to remain opr.n.
2 5.
D
- (b).
TRI:lzh Attachment l
6 m
O
. L AN eeuwetaa ACTION PLA 10 1**
2 n e...
OATE PREPARGO [ PREPARE 0 sv TITLg 07/08/85 l
T. R. Isley_
m,
REVIEW OF THE OPERATION OF THE PORV (Rev. 2) sescipic osJective E.
c :
w.
m PRWE ASSIGNED START TARGET DATE
.. STEP ACTION STEPS
- RFSPONSIBILITY TO oATE DATE COMPLETED,3 NUMsER C:
ALL STEPS OF THIS PLAN ARE TO BE PERFORMED IN ACCORDANCE WITH E
THE LATEST REVISION OF "CUIDELINES TO FOLLOW WHEN TROUBLE-
-SHOOTING OR PERFORMING INVESTICATIVE ACTIONS INTO THE ROOT CAUSES SURROUNDING THE JUNE 9, 1985 REACTbR TRIP".
I 1
Perform a visual inspection of the PORY and associated linkage.
T. Isley O'Neill u
Check for broken or missing parts, boric acid buildup, or other abnormalities.
I 2
Under the direction of the Crosby representative, disassemble T. Isley O'Neill the PORV. Check the internals for damage, proper clearances, abnormal wear, or foreign material. Also check the bellows for prepar fit or cracking.
3 Analyze the results of the inspection and data surrounding T. Isley Foust the transient to determine if differential expansion caused Straube the valve to stick open. This analysis is expected to take several weeks and will require the results of the valve inspection before proceeding.
M/ 7 -i ^,
(h.. G
==--
W G:CEE
?sE m*
E+r I
s y
E e
T l
EE 2
y TL Ls AP I
'o 0
DMO 9
C 2
RR A
P T
S T EE R
T E
a.
R Ee A 5 P 8 u
E /
T u
E R8 R T m
P 0 A A
/
T D a
ET 7 S~
~
a0 A0 L.1 D
D E
~
N O l
l l
G1 T l
l l
i i
i SA e
e e
N N
N
'O O
'O
=_
Y I
T L
I y
y y
E B MI e
e e
I S l
l l
RN s
s s
PO I
I I
PSF R
T T
T g
s-E n
y s
V i
a e
I y
l m
T f
e i
C i
r t
EJ r
8 e
l 6
i 0
v o
s r
t p
a
)
c y
t s
2 l
b n
a 5
. C o
e 5
v E
s c
l 1
P t
2 e
S i
f t
R
(
u o
a t
c u
r n
e o
i o
v b
c i
l a
V S
t a
R P
l d
v t
O E
o r
a T
r e
e P
S t
p h
s E
N n
o t
e H
O o
m I
C d
e i
T T
n l
t C
e a
c F
A O
h y
3 t
t c
N n
t f
i d
s O
o o
n a
I p
a e
T A
n t
l o
e V
R t
E i
s R
t O
i a
P O
a e
P s
r l
p V
E e
b e
R
/
H p
a h
0 O
4 T
o t
t 0
P s
6 F
e i
l e
y 0
h b
l t
h c
t a
u t
n r
t o
(
W E
k e
s b
e I
c p
n a
l e
o i
c v
VE h
r e
t y
a R
C p
R a
C r
N R
/
E A
O e.
P I
E E8 T
L TM 4
5 6
Ce 8
SU T
As T N
2 1
....,..vn........,
,a>
TROUBLESHOOTING ACTION PLAN ACTION LIST ITEM NtMIER 1.1 b -
-L ACTION LIST DESCRIPTION SYSTEM RESPONSE AUXILIARY FEEDWATER FV-20527, FV-20528 QUARANTINED EQUIPENT LIST ITEM MlHIER 12b, 12c j
RESPONSIBILITY OF Jim Field
(
PREPARED ~BY George Pactzun DATE January 7, 1986
}
s DESCRIPTION OF ISSUE:
This action plan addresses the failure of the Auxiliary Feedwater to "A" l
Steam Generator Automatic Isolation Valve, FV-20527, identified during the December 26, 1985 trip recovery.
In addition, this action plan provides
(
^
for investigation of the similar Auxiliary Feedwater to "B" Steam Generator Automatic Isolat. ion Valve, FV-20528.
FV-20527 and FV-20528 are normally closed control valves and were closed prior to the transient. During the transient, the failure of ICS caused the control valves to go to midposition with no remote control capability.
In an effort to reduce Auxiliary Feedwater flow, operators were dispatched 9-to locally manually close the control valves, FV-20527 and FV-20528 using side mounted hand jacking mechanism.
The "B" Auxiliary Feedwater control valve was partially closed by an operator.
The operator though he had completely closed the valve at this point. Feed-water flow to the "B" Steam Generator decreased by approximately 60%.
The "A" Auxiliary Feedwater controi valve was closed manually by an operator.
The operator believed that the valve was.only 80% closed. A cheater was used on the "A" Auxiliary Feedwater control valve manual operators and damaged the operator.
The "A" Auxiliary Feedwater control valve reopened.
"B" Auxiliary Feedwater control valve, FV-20528, was found to be partially An operator fully closed the valve.
Auxiliary Feedwater to "B" 0TSG open.
was stopped.
j c
b O
Exhibit 3 (Continued) 4-20.
. (
)
SUPMARY OF INFORMATION SUPPORTING PROBABLE CAUSE:
\\,.
/
The Auxiliary Feedwater to "A" Steam Generator Automatic Isolation Valve, FV-20527, was manually operated in the closed direction af ter the valve was already closed. Excessive force was applied to the hand jacking mechanism with a cheater. The control valve popped open as a result of the force applied to the jacking mechanism with the cheater bar, shif ting the jacking mac'anism's attachment position.
The spring on FV-20527 forced the valve The jacking mechanism was no longer firmly attached to the FV-20527 open.
operator yoke allowing the valve movement.
An inspection of the valve operator FV-20527 revealed that the jacking mechanism had dropped approximately 3/4." The valve jacking mechanism is attached to the valve operator by one U-bolt and two hook bolts.
f A su'bsequent inspection of FV-20528 revealed a similar movement of the jacking mechanism of approximately 1/2."
It is not known when the jacking mechanism moved on FV-20528.
Flakes of paint on the FV-20528 operator were not as obvious as those flakes of paint on the operator of FV-20527.
n The hook bolts on both FV-20527 and FV-20528 are loose.
FV-20527 and FV-20528 are pnematically operated control valves. The valves are 4",1150 psig diaphram actuated control valves. The actuators are direct acting with reverse loading positioners.
Based on controled vendor instructions and detailed vendor drawings a list of probable causes was developed for the "A" Auxiliary Feedwater control valve failure.
The hand jacking position shif t may have been caused by:
1.
Excessive force on the hand jacking mechanism.
2.
Improper moanting bolt torque.
3.
Improper positioning of the hand jack mecnanism on the operator yoke.
Combination of the above may have been contributory.
e 4
1
' Exhitiit3'(Continued)'
4-21 a
Q L REVIEW 0F MAINTENANCE, SURVEILLANCE TESTING
[] '
h o work A, review of maintenance and surveillance testing history s ows n f
initiated specifically for the hand jack mechanism during the operating Both FV-20527 and FV-20528 have been history of.the plant,.since 1974.
reworked for seat leakage, March 1981.
The attached wor'k request history sumary sheet details all documented The majority of the deficiencies required work or. FV-20527 and FV-20528.
No correcting the valve's control circuits or indication circuits.
modifications have been performed on the valve's operator jacking mecha
'or valve yokes.
FV-20527 and FV-20528 are stroked' quarterly on Surveillance Procedure SP 210.01C, Quarterly Steam and Auxiliary Feed System Valve Inspection Test stroke times have been consistent through the and Surveillance.
testing history.
POTENTIALROOTCAUSE(S):
p)
The primary potential root cause is operator action based on the use o
(
cheater to close the valve after the valve, FV-20527, was already close P'otential root cause, contributing to the valve failure are:
Excessive force on the hand jack mechar. ism.
1.
2.
Improper mounting bolt torque.
Improper positioning of the hand jack mechanism on 3.
the operator yoke.
l 4.
Operator training.
Area lighting, enabling the operator to see the 5.
indicator.
Valve stem position indication method.
6.
Combinations of the above may have been contributory.
OUT1.INE OF TROU8LESH00 TING PLAN:
The focus of The scope of this plan encompasses FV-20527 and FV-20528.
the maintenance instruction will be on the hand jacking mechanism an I
Potential root causes will be resolved attachment to the operator yoke.
by following the guidelines of.this troubleshooting plan.
b e
-,m,,%_e-,,,.y
-,.,-- _ _.,y__,
,-wg,--w--.
,,,,-y_m
r----,,.-,,-
w
-o.
' Exhibit 3 (Continued)
'4-22 1.
J
. OUTLINE OF: TROUBLESHOOTING PLAN (CONT):
j5
, - f 1-
&,f
- 1. ' Notify the NRC/NRC Resident prior to performing troubleshooting.
The purpose of this notification is to allow the NRC the Lopportunity to observe the troubleshooting.
- 2. - Confirm proper application of jacking mechanism with vendor information.
Document as found conditions of the valve operator (limit to 3.
those conditions which can be recorded without changing conditions).
Photograph valve conditions including valve position indicator.
Include QC hold points in the Maintenance Instructions as required.
~ 4.
Remove hand jack mechanism from valve operator.
- 5.. Disassemble hand jack mechanism.
6.
Inspect hand jack mechanism parts for damage and wear.
7.
Determine the root cause from the evidence obtained during troubleshooting.
8.
Notify NRC Investigation team of the root cause determination prior to proceeding.
DATE /-7-[d APPROVED B 4.,'
l
'Actiori/ List Coordin'at
- SMUD c
DATE RELEASED FOR IMPLEMENTATIO$ BY Action List Coordinator - SMUD E
S 6
e e
r t
i{
4xhibit3~(Continued) 4-23 J
y WORK REQUEST HISTORY-A_
y
-(,4
.FV-20527 DATE:
REQUEST WORK PERFORED Both Open & Closed BLPB's Tightened loose mechanical coupling on limit 5/21/75
~
- stayed lit when an open switch.
command was given.
1/12/76 Valve leaks thru.
Calibrated E/P FY-20527 I&C'to stroke & ncte
- extra novement, if any.
+
11/18/76 Valv.e leaks in hand Void - duplicate WR position. Placed valve in Auto, valve stops leaking.
1/9/78 Perferm PM on FY.
1/29/80 Terminate and test Performed STP-856.
H1SS Separetion circuit.
(
3/13/80 Stroke' valve from Bailey bperationallytestedthevalvebystroking Control 0-100-0%.
it from the control room. Stroked fully Verify valve movement open and closed, as verified by local locally at valve.
observations at the valve.
2/3/81 Valve leaks thru Removed valve internals for inspections..
excessively when in Found internals in good condition. Replaced closed position and very hand operators. Replaced Gaskets.
little D/P across it.
Stroked.
Must be restroked or repaired.
3/20/81 Valve position indication Adjusted switches for proper open/close incorrect. When valve indication. found wire (C-43) on switch closed - indiation on 4 (N.O.) contacts wire (C-33) on switch 2 H1SS shows open, closed (N.C.) contacts.
and auto lights all Mov2d wire C-33 to switch 4 N.C. contacts.
illuminated.
Moved wire C-43 to switch 2 N.C. contacts a.
per E-205, sheet 29.
6/29/83 Valve fails to close Relay EFWB is not energizing FY-20527A when BLPB pushed.
to close valve. contacts in EFWB relay (17 and 18) were normally closed in tne relaxed state. Corrected the problem i
per print E10.07A-3, sheet 1 of 2.
Correct position of this contact is normally open in the de-energized states. Tested valve - operates properly.
\\
---,,r+.--
--m-,-.---re.--,,-,e..-,r..-.,..-.-.w--
,--,-..,,,,.-.--,,---..,.---,-------.,.-.--.-.---,--.--._,....w.-m-----v-,,-
-c
' txhibit 3 (Continued) 4-24 FV-20527'(continued)
DATE REQUEST WORK PERFORED
.e T.
t 1/29/85 Reroute circuit II1F205BE Work complete 1.A.W. applicable DCN's.
7/10/85 Valve allowed some Valve stroked OK air supply checked OK, leakage during per-E/P cell OK formance of the AFW Pump.
Surveillance. Orange stickers placed.
9/23/85 Packing leak (Stem and Adjusted packing 2 flats to stop leak.
between gland follower)
Control room stroked & timed.
found during SP 210.01C.
O e
e o
t l
-=
- ---.-ve m-y
,--w
.y
1 Exhibit 3'(Continued) 4-25
~
m WORK REQUEST HISTORY
},'
Ad
'FV-20528 e
, DATE <
REQUEST WORK PERFORPED
' Valve does'not respond Repaired Analog Memory module #5-8-15 5/14/76
' to Bailey controller in ICS & benched checked OK. Replaced l.C. U-1.
(
10/30/78 Valve failed open Close switch does not operate S.V. only Auto and Open. Changed Auto and Closed light bulbs. Placed in Auto and valve went closed. Operated several times and it did not fail.
L'
'5/8/79 Valve operator loose TjghteneddownlocknutFV-20528.
l on top of valve Stroked valve.
9/11/79 Perform PM on FY Calibrated FY, set limit switches and checked solenoid & H/A station control FV-20528 from control room.
-3/13/80 Stroke valve frnm Stroked valve from control roore and l
Bailey control verified valve full stroke locally at 0-100-0%. Verify valve.
l fm f
i valve movement O
locally at valve.
7/2/80 8tPB located on H1SS Found wires C43 & C33 on wrong switches in control room has and on wrong contacts. Found cams in 4
all three lights wrong position, moved wires C43 to 2 NC (Auto,Open& Closed) switch & C33 to 4NC switch. Reversed on when valve is cam #2 and adjusted for proper indication actually closed.
per E205, Sheet 29.
8/19/80 With valve fully open Found microswitch not opening on full open.
the close light does Adjusted switch and tested to control F
not go out. Please satisfactory.
i-repair.
8/20/80 Indicates intermediate Void - duplicate WR position when full open and indicates closed with controller at approximately 25%.
Removed valve internals for inspection, o
d 2/3/81 Valve leaks thru excessively when in Found 8" diameter 1" red rubber gasket closed position and material. 8teplaced hand operators.
~
with very little D/P Jammed in valve internals, stem bent across it. Needs to straightened, stem-replace gaskets.
l.l O be re-tested or re-paired.
t 9
.-y----
-,__.,.,,,,.ww,.
,,- m-,,--m, www_w_,,,._,.e.
,,,,,my-,.
a,,-
w_,.__
,v m.,
7,.
~
Exhibit 3 (Continued) 4-26
- FV-20528 (contimurd) i s.)
DATE.
REQUEST WORK PERFORED 4/4/81 Both Open & Closed Adjust limit switches
' control room indicating lights are illuminated when valve is open.
4/30/81 Body to Bonnet leak Torqued Body to Bonnet Bolts to Engineering requirements.
5/28/81 With~ valve open still Adjusted switch for close indication have closed indication on 8LP8 6/18/83 Line-up system as per Voided valve lineup sheet. Fill and vent system for Hydro Test ISI 12 3/4 and 3094.3 6/16/83 Provide Craft Hydro-Completed set-up & Hydro Test support on static Test 3094.3 3094.3.
(
)
6/16/83 Provide calibrated gage Provide 2000# gauge.
k/
0-2000 1% full scale for Hydrostatic Test ISI 12 3/4 5/2/85 Open & Close indication The Emergency Feedwater Valve would not close completely, an investigation revealed that a modification crew lifted the wires that control the valve. The wires were reconnected and satisfactory operation was obtained.
a D
e
c; -
Exhibit 3 (Continued) 4-27
,~
t
-' w_,
b i
t 1,.
ACTION PLAN g 8
TITLE: Action Plan'for Mainfeed Pump Control System I
Nj CHAIRMAN REV DATE REASON FOR REVISION BY TA3K FORCE
[/[g O
6/18/85 Initial Issue i
V l
Rfc'sJungo39g5
-w--
_f.w.,,,.,--w-em-w_,,
,.,.,,.,,w,7-,-y_%--m,%.7,w-__y m__-y,.y--,------m
,,y-
- Exhibit - 3' (Continued)
'4-28 TITLE:
ACTION PLAN FOR MAINFEED PtBIP CONTROL SYSTEM
'A e(e
\\
/
Report by:
Jeff Blay' Plan No. 8 H
Don Missig Tom Isley Al Topor Page 1 of 8 Date Prepared: June 18, 1985 This report has been prepared in accordance with the " Guidelines to Follow When Troubleshooting or Performing Investigative Actions into the Root Causes Surrounding the June 9, 1985 Reactor Trip", Rev. 2.
INTRODUCTORY STATEMENT This action plan is the first step in addressing Confirmatory Action Letter Item 4a, establishing the cause of main feed pump turbine (MFPT) 1-1 trip. Item 4b will be addressed at a later date.
SUMMARY
OF DATA:
The following is a discussion of the events which took place prior to and shortly after the No.1 MFFT trip on June 9,1985.
On June 9, 1985 at approximately 1:22:49 computer alarm Q 626 indicated
(
"HFFT 1 Main Oil Pump 1 ON".
This indicates the standby main oil pump started approximately 12 minutes before No.1 HFPT tripped. The Data Trend Table for No.1 MFPT speed indicates that turbine speed increased 29 RPM and then decreased 23 RPM at approximately the same time the standby main oil pump started. This indicates that control valve movement dropped the hydraulic header pressure to <170 psig, therefore starting the standby main oil pump.
Since the MDT 20 control system was installed, valve movement, as de-scribed above, has started the standby main oil pump due to the quick c
response of the unit. Another indication that the control valves moved is the feedwater flow recorders. Approximately 12 minutes before NFPT 1-1 tripped, the, charts indicate a change in feedwater flow to both Steam Generators. -
7 j
The data available concerning No. 1 MFPT trip indicates that the trip was caused by an actual overspeed condition. Recording charts, booked up after the June 2 problems, show that Limit Switch LS16 was the first indication of a trip. LS16 provides tripped indication of the trip dump valve. Under normal conditions the trip dump valve will trip due to solenoid valve SV-12 energizing, the manual trip lever being actuated, or The by the emergency governor plunger due to an overspeed condition.
chart recorders indicate that the hydraulic trip solenoid valve SV-12 did not energize when MFPT 1-1 tripped. Therefore, the trip protection devices associated with SV-12 have been eliminated as possible causes of the turbine trip.
e,--r---,-,gw-
,ne,--n
-,,,,m, -, _ -, -,,
_,,-w--_n
Exhibit 3ICntinued) 4 29 Using the computer readout of turbine speed as an indication for speed
}
change with respect to time, it can be seen that NFPT 1-1 increased speed e
("j by approximately-1591 RPM between 1:34:24 and 1:34:53. This change in speed would be more than sufficient to reach the setpoint for the emergen-cy overspeed plunger to actuate therefore causing the trip deep valve to trip.
The emergency overspeed trip device should actuate between 5866 RPM and 5984 RPM (reference: MFFT Manual GEK 83602). Testing performed after the MDT 20 was installed during the 1984 refueling outage shows that NFFT 1-1 tripped on overspeed at 5920 RPM, 5888 RPM, and 5892 RPM. This testing was performed per PT5136.03, MFFT Overspeed Periodic Test, which requires three consecutive acceptable overspeed trips.
Another indication that MFFT 1-1 speed increased is the feedwater flow charts. At approximately 0135 on June 9, a step increase of approximately 2.5 apph feedwater flow occurred for total teedwater flow to Steam Genera-tor 1-1 and 1-2.
At this time, MFPT 1-1 was in "AUT0" and MFFT 1.-2 was in
" HAND". This rapid change in feedwater flow indicates that MFPT 1-1 c
increased speed, therefore increasing total feedwater flow to the Steam Generators. The turbine speed increased until MFFT 1-1 tripped due to an
~
overspeed condition which initiated a plant runback due to a loss of MFPT 1-1 above 55% power.
Following the trip MWO 1-85-1935-00 was initiated on June 9th to attempt to troubleshoot the cause of the NFPT trip. Under this work order voltage readings were taken on MFPT 1-1 and compared to readings taken on MFFT 1-2.
[s No significant differences were noted. All work on this MWO was halted on June 9th.
Maintenance And Test H' story The HDT 20 control system for the NFPTs was installed during the 1984 4
refueling outage. After installation of the MDT 20 control system, Test Procedure TP520.83, Main Feedwater Pump Turbine and Auxiliary Support Systems, was performed to test the equipment.
Testing requested by MPR Associates, Inc. was performed by TED personnel on installed equipment in November and December of 1984 which included:
3 A)
A test to establish the dynamic input / output characteristics of the MDT 20.
B)
A test to establish the steady state input / output characteris-tics of the MDT 20 valve positioner.
C)
A dynamic response test of the MDT 20 valve positioner.
D)
A dynamic response test of the MDT 20 governor during feedwater flush.
Exhibit 3 (Continued) 4-30 Analysis _of these tests by MPR concluded that the IEFT-20 governor will-
'p)-
- provide satisfactory feed pump differential control with internal settings i
as recommended by GE and the Integrated Control System (ICS) settings Ad established prior to the outage with the POIC governor.
- Discussion of events concerning April 24th trip:
During operation at 98% full power a flux / delta flux / flow RPS trip oc-curred. Approximately eight seconds after the Reactor trip, MFPT 1-1 tripped. The cause of the MFFT trip was never positively identified.
Testing was performed to determine if the thrust bearing wear detector trip circuitry could pick up if the standby oil pump is started. Test gauges were installed per MWO 1-85-1442-00 in place of the pressure switches and the standby oil pump was cycled to see if pressure would increase to the trip setpoint. During this testing, pressure did not increase to the trip setpoint. The turbine was also ren through different speed changes to determine if oil pressure could have dropped to trip the turbine. The -turbine speed was increased at three different initial speed settings consisting of the following:
1) 3700 RPM to 3900 RPM 2) 3500 RPM to 3900 RPM 3) 3300 RPM to 3900 RPM This testing indicated that the oil pressure did not decay to the trip setpoints.
)
Periodic test PT 5136.06, MFFT Emergency Overspeed Governor Tests, was L/
performed to test the overspeed governor. This test was completed success-fully.
In addition to the testing which was performed the following instruments were recalibrated:
1)
The active and inactivate thrust bearing wear detector pressure switches.
2)
The turbine bearing low oil pressure trip switches.
3)
The feedpump bearing low oil pressure switches.
4)
The main feed pump high discharge pressure trip switches.
5)
The NFPT vacuum trip switches.
6)
The RFR target speed voltage was adjusted from 4.0090 VDC to 3.6045 VDC.
Discussion of events from June 2nd trip:
During main turbine control valve testing, a high turbine vibration signal tripped the main turbine. The ARTS tripped the reactor. Within four seconds after the turbine / reactor trip, both main feed pump turbines tripped.
Pri. Theory The theory behind both the MFPT's tripping concerns the following four parameters:
4 a
4.-~-----mam,e,mn_,
w-.-,.,.gmm
. m,w
,n_
_.mm.,
-w.,
,,,_,n
Exhibit 3 (Continued) 4-31
- f k Rapid Feedwater Reduction (RFR) target speed
'? f-%
1.
- /
Y
.being set too high due to not adding in a bias to r
T
/ -
the RFR setpoint.
~
From January, 1985 until April 24, 1985, the RFR
- target speed was thought to be set at 4800 RP!f, when in fact it was actually 5150 RPtt.
i Following the April.24 trip, the RFR target speed was thought to be reset to 4600 RPM, when in fact it was actually 5000 RPtt. Reference ifWO 1-85-1489-00.
i Following the June 2nd trip, it was found that a voltage bias needed to be added to the RFR setpoint. RFR target speed was reset to 4600 RPit. Reference IIWO 1-85-1908-00 Itain steam header pressure increasing to approxi-2.
mately 1070 psig after the reactor tripped causing the MFPT speed to increase.
Booster feed pump suction pressure increasing due 3.
to increasing dearentor level plus dearentor This would cause osin feed pump pressure.
discharge pressure to increase.
4.
Feedwater valves partially closing down causing ftFP discharge pressure to increase.
(
Based on the above four parameters, there is a possibility that the IfFPT's tripped on high discharge pressure of 1500 psis, which is one of the trips that could have tripped both pumps almost simsultaneously.
Quick response time associated with the IfDT 20 Alt. Theory hydraulic control system could cause hydraulic oil pressure swings which could have activated trip circuitry. This theory is not conclusive based on the following:
Testing indicated that the itFFT's would not trip I,
after the hydraulic control system was subjected to rapid swings by cycling the control valves.
I Based on the above theory, the ifrPT 1-1 control valves were cycled repeatedly through full stroke cycles as fast as possible with the GE representa-This was performed to try to decrease the L
tive.
oil pressure to activate trip circuitry associated with the hydraulics. No itFFT 1-1 trips were activated. The testing indicates that the PfDT 20 hydraulic control system responds from the valves
\\
D dumb i
~ ~ - - *
- - - + -,,,,.
. ~
Exhibit 3 (C*ntinued) 4-32
. crack point full open in approximately 0.6 m
)
seconds.
- [J.
. Continued testing by GE identified that the #1 MFFT could be tripped when l
E' stopping the #2 Main Oil Pump (NDP). If the #2 MOP was left in-service It for a period of time and then turned off, the fl NFPT would not trip.
was recommended by GE not to turn off the #2 MOP on #1 NFPT until after it had'run for awhile. This was only a short tern solution to the problem.
I.ong ters solution will be to inspect both NOP discharge check valves p
along with PRV3 during a me.jor outage.
While increasing power and performing PT5136.01, MFFT Stop Valve Periodic Test, on #1 NFPT, #2 MOP came on during stroke valve testing. The operators left #2 MOP on for approximately 20 minutes as instructed and then shut-down the #2 HOP after which the #1 MFPT tripped. At 0155 the plant was at approximately 56% Power and experienced a runback to 55% power.
Repeated testing after the 6-5-85 0155 NFFT 1-1 trip:
i 0630 After stopping the #2 MOP MFFT1-1 would trip.
1 0800 Af ter stopping #2 HOP the MFFT tripped two out of six times.
1400 After stopping #2 MOP the MFPT would not trip. This was performed numerous times with the MFPT on turning gear and at speeds of approximately 4000 RPM's.
1900 Broke vacuum to install additional instrumentation to monitor the active thrust bearing pressure switches.
l 6-6-85 Additional testing was performed and the MFFT would not trip t
when either #1 or #2 MOP was stopped.
GE Tactory Personnel and Representative felt that the #2 NOP discharge check valve was sticking open and remained open momentarily after stopping #2 MOP. Under this condition, il MOP would pump oil back into the #2 MOP impeller and the 55 psis 7
i header pressure would decrease.
It is possible that the check valve remained open long enough to have the pressure control i
va,1ve that reduces pressure from 250 to 55 psig (PRV3) to open to maintain header pressure at 55 psig. After the #2 MOP i
discharge check valve seated, preventing back flow, with PRV3 open the 55 psig header could experience a pressure surge picking up the thrust bearing wear detector trip circuitry.
Based on repeated testing, the cause for the check valve to remain open evidently cleared itself.
i Strip chart recorders were connected to monitor particular electrical signals and oil system pressures af ter the June 2 trip to determine the l
\\
i f
l l
i
..s Exhibit 3 (Continued) 4-33 cause of NFPT 1-1 trip which initiated the reactor trip. The recorders 1
.[D were booked up to soottor the following information'for MFFT 1-1.
);
A CTRM Cabinet Room:
1.
Lebe Oil Pressure to feed pumps (PS25) 2.
Bearing Meader Pressure (PS19) 3.
Thrust Bearing Wear (PS 2 & 12) 4.
Mais Feed Pump Discharge pressure (Q628) 5.
Speed Reference Signal (TP111)
Locally at NFPT 1-1:
1.
Limit switch LS16 2.
Solenoid valve SV12 3.
Nydraulic header pressure 4.
Control oil pressure 5.
Thrust bearing wear detective (Active)
FAILilRE ETP0 THESES SIRetARY On the April 24th and June 2nd trips, the reactor tripped and the NFPT(s) tripped shortly afterwards. On the June 9th trip, the MFFT initiated the transient which caused the reactor trip. On the April 24th and the June 2nd trips there was no apparent MFFT overspeed condition. On the June 9th trip we very clearly saw an indication of a MFFT overspeed condition. As a result, we feel that the June 9th trip is unrelated to the previous trips. W will continue to monitor electrical and oil pressure signals.
On June 9, the chart recorder monitoring the speed reference signal shows that demanded speed for HFPT 1-1 was steady until actual turbine speed in-creased and the main feedwater control valves began to close due to the increased feedwater flow. The ICS speed control for the NFPTs is derived from the pressure drop at.ross the feedwater control valves and from the feedwater demand signal. Due to a developed feedwater flow error signal, the main feedwater control valves closed down and the pressure drop across the valves increased. The ICS turbine speed control circuitry responded properly by reducing the speed reference signal (demanded turbine speed).
This indicates the ICS input signal and the MDT 20 electronic circuitry which produc*es the speed reference signal did not cause the overspeed condition. This also rules out an inadvertent RFR initiation.
An electrical connection probles/ malfunction may have developed in the MDT 20 circuitry (excluding the circuitry producing the speed reference signal).
Another possible explanation for the overspeed trip is a hydraulic /mechani-cal contrel system malfunction which drove the steam control valves open therefore causing an overspeed condition.
i'
?
-.,nr
Exhibit 3 (Continued) 4-34
)
Another possible cause for the overspee[I condition could have been a
/ m-\\
mechanical coupling failure betwen the pump and turbine. Since feedwater
-()
flow increased as turbine speed increased, this possibility was ruled out.
An industry poll by MPR revealed that an overspeed failure occurred in an Indiana power station due to a faulty MDT-20 speed circuit. A former G.E.
Service Representative was contacted, and he recalled troubleshooting a high speed failure due to a faulty frequency to voltage integrated circuit.
There is indication from the feedwater flow recorders that the problem may be intermittent, which may make it extremely difficult to locate the problem. This fact is also recognized by G.E.
CHANGE ANALYSIS 1.
Until the 1984 refueling outage, the NFPT's were equipped with mechanical / hydraulic speed governors (General Electric Model NHC).
These NFFT's were replaced with more modern electrical / hydraulic speed governors (General Electric Model MDT-20) installed per FCR 81-075.
After the April 24, 1985 trip, the following work (Items 2 through 9) were performed:
e 2.
Installed 'Iest gauges on 4-24-85 in place of the active and inactive thrust bearing wear trip pressure switches PS 2715 and PS 2717.
[v Disconnected the test gauges and reconnected PS 2715 and PS 2717 on 4-25-85 per MWO 1-85-1442-00.
3.
Recalibrated PS 2715, Active thrust bearing wear trip pressure switch, per MWO 1-85-1451-00.
4.
Recalibrated PS 2717, Iractive thrust bearing wear trip pressure switch, per MWO 1-85-1451-01.
5.
Recalibrated PSL 1161, MFPT 1-1 turbine bearing low oil pressure trip switch, per MWO 1-85-1451-02.
l 6.
Recalibrated PSL 1192, BFP 1-1 bearing low oil pressure trip switch, per MWO 1-85-1451-03.
7.
Recalibrated PSH 506, MFPT 1-1 discharge high pressure trip switch, per MWO 1-85-1451-04.
8.
Recalibrated PS 2535A and PS 2535B, MFPT 1-1 low vacuum pressure trip
~
switches, s er MWO 1-85-1451-05.
(
9 '.
Recalibrated the Rapid Feedwater Reduction (RFR) Target Speed Setpoint l
from 4.0090 VDC to 3.6045 VDC which was thought to correspond to 4600 RPM.
e l.
Exhibit 3 (C*ntinurd) 4-35 After the June 2,1985 trip, the fo11owing work (Items 10, 11, 12 and
.A
- 13) were performed:
'{
h.
i
.L/ -
10.
Additional MFPT System test points were monitored and recorded by
~
field mounted strip chart recorders installed per MWO 1-85-1887 -
and 01.
11._ Again recalibrated'the RFR Target Speed Setpoint from 3.6045 VDC to
-2.000 VDC which corresponds to 4600 RPM per MWO 1-85-1908-00.
- 12. Operational change: #1 Main Oil Pump was changed from primary to backup service and #2 Main Oil Pump was changed from backup to primary service.
- 13. Operational change: #2 MFPT was placed in ICS manual operation from automatic operation. #1 MFPT was left in automatic operation.
MYPOTHEST.S INVESTIGATION Based on the information gathered, it appears that several conditions could have caused MFPT 1-1 to overspeed:
~
1.
I.oose connections associated with the electrical circuitry for the MDT 20 system.
2.
A circuit board component saifunction.
3.
Hydraulic / Mechanical control problem.
I e
o e
I t
l I
t
g
/
(
\\
ix x
PLAN Nuwst a Paos ACTION WAN Rev. 0 8
1
._4 TsTLt__.
._..._.__,,__m...m,,,,
DATE PREPARED PREPARED eV 6-18-85 J. E. Blay
~
~
HFPT I-l Control System PrcH en secciisc ohictdy
-- - D r -E.- M i ss h i
?.. E. T: :-
T. R. Isley To' determine the root cause of MFPT l-1 overspeed trip on 6-9-85 PRIME ASSIGNED START TARGET DATE STEP I
NUMsER RFSPONSistLITY TO DATE DATE COMPLETED
_ All steps of this Action Plan are to be performed in accord-ance with_the latest revision of "Guldelines to Follow When Troubleshooting or Performing Investigative Actions Into the Causes Surrounding the June 9. 1985. Reactor Trip".
Root Action plan steps will be performed in the seguence listed.
1 lease connections: Visual inspections and troubleshooting will J. Blay be performed locally at the pump and at the control cabinet.
"E "I11 be maintained to document the troubleshooting AI performed and the findings. A DVOM or an oscilloscope will be used to monitor connections,yh11e performing these checks.,_ _
- -, _ a n u
.a. -..ma=.--
~
y$
ET EE Vc TL SiD 4
AP B
DM 8
D O
E R
C 2
E l
A l
P T
O E.
'+
A RJ EE MT P
P A
AD D
T E
R t
g A 5 A
P 8
t E
T E
u R
R T N8 P 8 A A 1
N E -
D A
T 6 L
A P
D D
0 N O
.v I T e
R A
YT IL I
y B
a I
S l
I N B
O 5
P S
8 F
J n
9 6
y r
n l
y t
o k
l l
r i
i l
c_
w i
t u
s e
p l
c l
h w
r c
s e
u r
a i
t n
h c
i n
t r
C g
a i
o t
i i
3i-e u
l d
v g
c d
C k
s e
i e
n r
A n
c T
i i
a e
a t
c p
e s
s c
c b
u d
n d
p
- e r
u o
e e
e e
e e
n h
d m
r e
i v
e t
a r
e F
c o
ri v
m o
y f
r i
f f
r e
n o
c i
l t
o e
r t
R o
f l
a b
e i
i E
t k
p u
t t
d Ps c
f i
e T
n c
l P
e e
l s
r l
s s
F s
h i
t i
L o
y u
e c
w s
e C
P r
M
- n r
e r
e t
e e
o p
l s
t a
p v
e i
b h
S i
e a
t u
l v
u P
t r
c n
e t
k a
l c
y s
t c
i e
h s
c Y_
a r
a E
m T
V i
m e
f S
n E
r m
t e
i l
o u
C t
t r
P C
s b
N f
c s
t e
t r
o e
O l
a e
u n
t d
n o
r o
e a
l j
e n
e o
=
l I
t r
s T
P u
C m
f e
d m
i e
i i
t a
a A
o a
u p
t P
f r
m c
t n
c f
S a
i e
e n
n a
o o
o m
l t
t e
o n
d t
m p
n e
s n
u r
m y
o o
t O
d o
d a
S o
A g
s o
n i
S r
p c
W n
t r
d t
l m
e M
a a
n d
a o
a l
e o
r d
o u
e r
v n
i e
d e
b d
e e
r g
o h
c, d
h e
n e
p p
e i
r t
d t
m i
r R
S O
S s
tn e
r e
r a
a o
n a
h r
o t
s l
n o
t e
f n
g u
)
)
)
)
o C
m b
p r
i n
c 1
l t
v i
i l
r r
e a
i i
l i
t t
e t
e t
p m
d t
l c
l t
t d
s n
r n
e u
n i
e e
i a
u l
b b
f P
F T
d c
t N
P r
F o
i N] A M
T C
s l
i sN.
R O.
/\\
P E
=
I E
E B T
L TM 2
C.
TI SU
=
A.
T N
T ',
,/
)
s ACTim 'u.b
's re..a numenia _
ct so me Rev._0 8
3 4 DAT E PREPAREO PnEPARED SV TsTLE 6-18-85 J. E. Blay MFPT l-1 Control System, Problem p
2:. p ysty srEcipic concTivE T. R. Isley
'Tn determine the root cause of NFPT l-l overspeed t rin on 6-9-85 PRIME ASSIGNED START TARGET DATE STEP RF.SPONSIBILITY TO DATE DATE COMPLETED NUW8ER J. Blay 3
Hydraulle/ Mechanical Control System:
a] Testing of the hydraulle and mechanical control sygem will be performed oer CE recommendations. Tests such as cycling the valves thrcunh full stroke may be performed along with other GE recommended tests.
While moving the valves, testleg of appropriate electrical signals may also be performed.
b) Sample oil and inspect filters for contamination.
J. Blay 4
If the root cause is not determined from steps 1,2, or 3, then J. Blay an Aux Steam / Main Steam run of MFPT l-1 will be performed to obtain data to compare to previous information gathered earlier by MPR.
,CE may also perform addlttonal checks.
f
a.
D
,*p E
T y
5 m
EE Ya f',-
TL 4
d D
O E
R C
E ;_
A E4 P
T G
E.
EE A
MJ ;
P P
GT RA
[l AD D
T E
R R
EG' A5 P
M 8
E T
U R
R T E
N8 P 8 A A 1
1D N
E -
S A
T6 L
A P
D D
E NGO 1 T 0
.ve R
Y T
I L
I y
y E B a
a MI I S l
l RN B
B POP S
F J
J G
5 8
4 9
4 r
6 r
g o
o r
n u
a a
3 b
3, s
h p
2, a
c e
2, E
t r
i r
1 i
u 1
h v
i t
r F
l c
c s
i s
u r
t E
d p
t a
p s
>e e
e a
f e
c e
t t
d p
s E
a s
e c
s C
m i
r m
e m
r e
s e
o o
t o
o c
v r
t a
r f
e o
f c
f r
E t
o e
s d
p 1
d n
l e
e e
m l
n s
o n
e i
t i
b T
m e
m P
r b
t r
l M
F e
p e
l m
t i
H t
l m
e l
e e
w e
f d
i t
d l
o w
t k
b t
a t
c r
s o
s o
e o
e n
d n
n h
P u
r a
c a
s a
s M
o n
i g
m c
i e
b I
n t
t e
e i
s o
s t
s s
r y
o u
i t
u i
S r
a u
s a
v c
c e
c l
e r
t d
a h
t i
t i
t r
t o
c s
o e
s t
o s
o l
e n
e r
e e
r f
t o
n h
r C
t e
t t
e a
r n
h s
h e
1 r
t n
t n
g e
e r
e g
l t
f h
o f
h e
e I
t f
I t
m T
d N
F
)
F 5
)
JA L
M 7
a b
[(T N
R O.
P E M
I E
E 8 T.
L TM 5
C T
A s.
i SU T
N
BIE USE DEY fW GUIDELINES FOR THE PREPARATION OF THE j
[
INCIDENT INVESTIGATION TEAM REPORT e
-v IIT Procedure 5
-5.1-Purpose::
\\
'To provide guidance for the p(reparation, release and distribution of theIIT) report res Incident Investigation Team
5.2 Background
The purpose of the incident investigation report is to convey in clear and con-cise language the results of the IIT investigation. The report constitutes the public record by which the investigation will be measured for thoroughness, accuracy, and objectivity, and to which subsequent reference will be made.
Followup actions directed by the Executive Director for Operations (ED0) will
'be based largely on the contents of the report. The Office for Analysis and Evaluation of Operational Data will coordinate with the Director of the Office of Administration to prcvide staff to assist IITs in writing, editing, word
's processing and publication of reports through the Division of Technical Inforination and Document Control.
5.3 Writing and Publishing Guidelines
.These guidelines list.the sections that typically appear in an IIT report and
' O describe the general approach for how each should be written or by whom it Q will be compiled.
(Exhibit I shows a sample IIT report contents.) This procedure section also provides guidelines for the following report preparation requirements:
submitting graphics material tranrmitting advance copies of the report scheduling preparation of the report.
Also listed are the assumptions on which the report preparation schedule are based and required publication forins.
5.4 Report Writing Guidelines 1.
The cover, title p_aJLe, and spine will be sent to Graphics for preparation by the technical writer / editor assigned to the team.
l 2.
The NUREG number will be obtained by the technical writer / editor.
3.
The abstract should be 200 words or less, and describe the "what, where, and when" about the incident and the "how," as space permits.
It should l
state the team's task, that it was sent by the EDO, and that the report L
contains findings and conclusions. The abstract should not discuss findings and conclusions.
4.
The table of contents will be compiled by the technical writer / editor.
t 5.
The list of figures and tables will be compiled by the technical writer / editor.
l
.w-w
--.-.--m-_,,--_m
._-_.__-,-,-..-._,__.-._,,_,,.-~mm,,_..,_
b-2 6.
The acknowledgement section should list the names of team members.
~
7.
The acronyms and abbreviations section will be compiled by the techn' cal writer / editor.
In the text, terins for which acronyms are used should be 1
spelled out the first time they are used, followed by the acronym in parentheses. Thereafter, the acronym can be used. This practice should be followed for e_ach major section of the report.
8.
The report introduction should begin with a brief background statement y
containing the facility's name, utility, location, reactor type (or type of facility process and materials involved), and date licensed for opera-tion. The introduction should contain a brief description of the incident.
In a separate ?aragraph, the purpose and scope of the IIT's mandate should be described, followed by a description of what is contained, section by section, in the remainder of the report.
Findings and conclusions should not be discussed in the introduction.
9.
The IIT investigation process section should describe the methodology used by the team in conducting the investigation. This section should include a table of interviews and meetings identifying those interviewed by job title rather than by name.
- 10. The narrative section of the report tells the story of the incident in a
chronological order from start to finish.
Time markers should be used j
throughout the description to keep readers abreast of the sequence. The a
use of a.m./p.m. clock notations should be used since this section of the report will be most widely read by those unfamiliar with 24-hour clock notations. The use of transitional terms that specify time ("in the j
meantime," "at this point," "before," "after," "then") should be used also. The narrative should be written in the past tense and descriptions of activities of the people involved in the event should be in the third
=
person, unless someone is quoted directly. Quoted statements should be enclosed in quotation marks and the person speaking should be identified by job title. The narrative should not be interrupted with lengthy explanations. A sentence or two of explanation essential for the reader to understand the significance of what is being described is appropriate.
- 11. The system description section should begin by providing a brief overview statement of what function a system or subsystem performs and of how it is integrated with other pertinent systems before a detailed description of f
the system or subsystem is given.
Equipment and systems should be
]
referred to consistently. The tenns and abbreviations that are used in the text should be identical to those on figures.
4
- 12. The equipment performance sections and human performance sections should h
begin with a narrative description of the sequence of events associated a
with the performance described. While the complete narrative section of l
the report contains many " threads" that are interwoven throughout the event, the performance sections each describe a single " thread" from start i
to finish (e.g., the entire story associated with failure of a pump). An equipment performance section may contain some human performance aspects 9
(e.g., a personnel error caused the equipment failure), and vice versa.
=
The degree to which human factors concerns ought to be included in the j
equipment performance section, or vice versa, should be based on the
}
3 5
i
=
5-3
( _
dominant characteristic of the sequence and the relevance of the activity
- Q}
to the problem being explored.
In addition to describing what happened, the performance sections should explain why it happened (e.g., the results of any troubleshooting, the probable cause).
- 13. The oeuipment performance section, as with the system descriptions sect' on, should provide a brief explanation of the function or purpose of l
the equipment. Where pertinent, any problems the equipment had before the event should be described concisely.
- 14. The human performance section should be written from the point of view of the people who operate or repair the instrumentation and equipment being described. Operator errors should be described objectively, not judgmentally.
Judgments are appropriate for the conclusions section.
- 15. The precursors section should document all precursor events fully, care-fully distinguishing between facts and opinions. Opinions should be identified as such.
In general, this section should pertain to all similar events applicable to the event at the facility, e.g., if it could 17 have happened at that plant, it is a precursor.
- 16. A section of significant items of interest found during the investigation but that were not directly related to the event should be included in the t
mport as needed (e.g., a significant design deficiency that did not play i
a role in the event was found during the review of a drawing of a system).
O
. The findings and conclusions section should distinguish clearly between 17 findings and conclusions. A finding is what the team learned or "found" based on its investigation (i.e., factual infonnation).
For example: a piece of equipment failed; its failure caused the loss of a system; operators did not respond quickly to the system failure; procedure manuals do not address this specific sequence of events. A conclusion states a judgment and specifies the significance or implications of a finding. For example: the equipment failed because of poor maintenance; operators were nut properly trained to respond to the sequence of events that occurred; the procedures need to be revised to address this sequence of events. The findings and conclusions must be correlated carefully with those discussed elsewhere in the report. The findings and conclusions section should not introduce new information; i.e., nothing should appear as a finding or conclusion for which the bash is not provided in the report; conversely significant issues in the report should be reflected as findings and conclusions.
In general, for early drafts, it is easier to put the findings and conclusions in the text where they logically would occur and to label them with a heading, " conclusions." This way they can be easily identiiied when the findings and conclusions for the entire report must be compared for accuracy and consistency before being compiled in a separate section.
In later drafts they can be collected into a separate section and the labels in the text removed. This system makes it easier to ensure that there is adequate support for each conclusion.
i
- 18. The reference section should contain only accurate and retrievable refer-ences which are essential to establishing the basis or credibility of the
5-4 r~w IIT report. The reference fomat style in the NRC Style Manual, (V)
NUREG-0650 and in NCREG-0650, Supplement 1 are preferred. The technical writer / editor will assist with the reference fomat.
- 19. The appendices section should contain material that clarifies or supple-ments a finding or explanation crucial to the incident but that is so detailed or voluminou.s that it would impede readers if it appeared in the body of the report. Typically, this material includes calculations, extensive data suvunaries, pertinent memos and correspondence, trip mports, texts of interviews, and other information needed to support the team's investigation but not readily available elsewhere. Material from NUREG reports, for example, can be cited in a reference section rather than appearing in an appendix because NUREG reports are readily available.
5.5 Graphie Guidelines The following guidelines provide instructions for submitting work to the Graphics Section.
1.
All work should be submitted by the originator so that he/she can answer technical questions, if necessary. Figures should be coordinated with the technical writer / editor before being submitted to Graphics.
2.
Original artwork should be submitted when possible.
3.
For original artwork, instructions should be put in writing. The IIT J
f member should retain a copy of the artwork and instructions for future reference.
s 4.
IIT members should put their name and telephone number on the back of each figure submitted.
5.
Artwork from previously published work (from another report or manual),
should be submitted in the original or in the best copy available.
Changes should be marked on a copy of the original in red.
6.
If the original appears in a copyrighted source, pemission to reproduce should be obtained before the IIT report is issued. The technical writer / editor will provide the appropriate copyright release form.
7.
If appropriate, the name of the source from which the original was obtained should be acknowledged.
8.
For oversized artwork, the original, not a reduced version, should be submitted.
9.
Changes to existing artwork should not be marked on the tissue overlays.
- 10. The teminology and abbreviations in the text and in the figures should be consistent.
O
5-5 y
h
. The standardized eouipment diagram symbols provided in Exhibit 2 should 11 be used.
Intentional deviations should be marked with an asterisk and footnoted.
- 12. Zeros should contain a diagonal line through them (9) to distinguish them from the letter 0.
Likewise, the letter Z should contain a horizontal line through it'(3) to distinguish it from the number 2.
- 13. For photographs. requiring callouts (labels), the callouts and arrows should appear on the copied version.
(No writing should appear on the face of the actual photograph.) The original photo and a marked copy should be submitted together. As with other figures, the submitter's name and telephone number should appear on the back of work submitted. A felt-tip rather than a ballpoint pen should be used to write on the back of the original photograph.
14.
If the photograph is to be cropped, the crop m3rks should be marked on a copy of the photograph.
- 15. Paper clips should not be used on a photograph without padding.
5.6 Publication Foms The following foms are required to be filled out in order to publish the IIT report as a NUREG document.
1.
Fonn 426, Publications Release for Unclassified NRC Staff Reports. This form is filled out by the technical writer / editor and signed by the team leader.
2.
Form 335 Bibliographic Data Sheet. This form is filled out by the techni-cal writer / editor.
[
l 3.
Fonn 379, Manuscript Review and Cost Data. This fom is filled out by the technical writer / editor.
E.7 Distribution of the Advance Copy An Advance Copy of the team's investigation report is necessary because the final put,lished NUREG will not be available before the Comission briefing.
Each copy of the report will clearly indicate on the outside cover that it is an " Advance Copy," and will be stamped for " Official Use Only." Infomation contained in the report is not to be released until the day of the Commission briefing when a copy will be placed in the NRC's Public Document Room (PDR).
The technical writer / editor will consult with the team leader to detemine the proper report distribution contained in the transmittal memorandum (Exhibit j
3). As a minimum, the NRC Comissioners, EDO, Office Directors and Deputy l
Directors. Regional Administrators, and the IIT should be on distribution for an Advance copy. The Incident Investigation Staff (IIS) will make arrangements to have couriers deliver the Advance Copies to the Comissioners and to the EDO as soon as it is available.
s m
m
5-6 L
(h An additional 75 copies of the team's report will be required for the Co
~j sfon briefing and delivered by courier to the Office of the Secretary on the
- day of the bri.efing. These copies will not be marked 000 or " Advance Copy."
The EDO may fomard a courtesy copy of the IIT report to the affected ifcensee
'before the Comission briefing, and simultaneously fomard copies of the advanced report to the Public Document Room and the Local Public Document Room.
Following the Comission briefing, the EDO will transmit a copy of the team's U
final investigation report to the licensee and the staff for review and coment.
- The purpose for this.is to allow the licensee and the staff an opportunity to provide comments on the team's report prior to the ED0 defining and assigning follow-up actions to NRC offices.
. 5.8 Distribution of the Published RUREG The technical writer / editor will arrange for proper report distribution after consulting with the team leader. As a minimum, distribution should be made to NRC Branch Chiefs and above (technical offices only), including Regional Offices,- all resident inspectors, and enough copies to accompany the Generic Letter. In general, the Regional-Administrator of the affected Region should receive 15 copies and the Office for Analysis.and Evaluation of Operational Data (AE00) should receive 75 copies of the report. The final copies for IIT members will come from AE0D's allotment. The technical writer / editor should call each of the following offices to learn of their requirements:
1.
Office of Congressional Affairs 2.-
Office of Pub 1'ic Affairs 3..
Office of State Programs 4.
Office of International Programs 5.
ACRS 5.9 Schedule The IIT shall prepare and transmit its final report to the Commission and the ED0 in about 45 days from the time the team is activated, unless the EDO grants an extension of the schedule. The EDO will schedule a meeting approximately one week after the Advance Copy has been distributed for the IIT to brief the i
Comission on its investigation.
t The following writing / editing schedule provides guidance to ensure that the l
report is finished on time.
l Team's onsite investigation.
l Days 1-14 Days 15 Team members write their sections and include findings and conclusions in text.
Members prepare draft figures and select photographs during Q
this period to give Graphics adequate preparation time.
Original drafts are typed on the IBM 5520 work processing system.
k 5-7 Authors / team leader review and authors rewrite.
rm i
1 Drafts are revised on the IBM 5520.
Days 33 The team assembles an essentially complete draft of the report for each member to review. The Director and Deputy Director of AE00 should be given this draft for infomation and review as they deem appropriate.
(The purpose of the AEOD review is to provide suggestions to the
' team leader concerning the completeness of the report.)
Following this review, the team meets to discuss comments on each section.
(The team leader rewrites on the master copy as the discussion proceeds.)
The team leader's master copy is then revised on the IBM 5520.
The editor reviews each section.
o The authors review the editor's comments and resolve problems.
The team leader extracts findings and conclusions into a separate section, but leaves findings and conclusions in text.
The draft is revised on the IBM 5520.
The team meets to resolve team and AEOD comments. The team leader determines which AEOD coments to incorporate into the report.
The team leader (with the Director of AEOD) briefs the EDO Day 42 on findings and conclusions.
The team moves to the Electronic Text Processing Branch Day 43 (ETP, formerly CF'ESS) for'its final review and corrections.
The team makes final review of the complete draft for typos, consistency, and errors, and reviews findings /
conclusions for accuracy and consistency. Team members review the same draft (i.e., review sections in series).
The final draft is put into single-space format.
The team leader and editor review the final text, resolve typos, etc., and the team leader prepares a transmittal memorandum (Exhibit 3).
All team members should concur on the report and on the transmittal memorandum.
J 5
5-8 g(
i
~(V)
Day 44 The editor and team leader assemble the final version and
. send it to Reproduction..
Reproduction makes 25 copies of this " Advance Copy" version for distribution by courier to the Office of the Secretary for the Commission Briefing.
Day 45 Couriers deliver Advance Copies to Comissioners and the EDO.
' Day 46 The EDO will transmit a copy of the report to the licensee and staff for reviry and coment. Copies will also be lo sent to the PDR.
Day 52 IIT presents its report to the Comission.
Day 60 The EDO will define and assign follow-up actions based on the IIT report and coments received from the licensee and to a
staff.
Assumpticns Upon Which the Schedule is Based:
That at least three typists and IBM 5520 terminals will be available during the week and extra help will be available on the weekends.
That the team will schedule the completten date for the
. Advance Copy on a Monday so that the team can use ETP facilities and operators during the weekend.
.That it is prudent not to release the team's report for printing as a NUREG until after the Commission briefing.
That the team will work 10-12 hour days, including weekends and holidays, while on site.
That the team will work 8-10 hour days with a little weekend work upon its initial return to Headquarters.
That the team will work 12-14 hour days, including weekends, during the final 2-3 weeks.
4 O
l
5-9 i
Exhibit 1
's.,[
Sample Report Outline Abstract List of Figures and Tables The NRC Team for the (Facility Name) Event of (Event Date)
Acronyms and Abbreviations 1.
INTRODUCTION 2.
' DESCRIPTION OF FACT FINDING EFFORTS 2.1 General Approach 2.2 Interviews and Meetings 2.3 Plant Data 2.4 Quarantined Equipment and Troubleshooting Procedures 3.
NARRATIVE OF THE INCIDENT 4..
SYSTEM DESCRIPTIONS
-5.
EQUIPMENT PERFORMANCE s
7
.1, j 6.
HUMAN PERFORMANCE v
6.1: Introduction 6.2 Shift Staffing 6.3 Event Recognition 6.4 Adequacy of Procedures 6.5 Compliance with Procedures 6.6 Role of the Shift Techical Advisor 6.7 Licensed Operator Training 6.8 Nonlicensed Operator Training 6.9 Radiation Protection and Emergency Plan l
l 7.
PRECURSORS TO THE EVENT AND RELATED NRC AND LICENSEE ACTIONS 8.
SIGNIFICANCE OF THE INCIDENT l
9.
ADDITIONAL ISSUES
- 10. CONCLUSIONS 10.1 Principal Findings and Conclusions i
10.2 Other Findings and Conclusions APPENDIX
(
Executive Director for Operations memorandum establishing the team.
Q/
-,..~._.... _., _. _, _. _.. _, _ _. _ _ _
m
,g i
Exhibit 2 Graphics Attachment VALVE SYMBOLS
,~;.
~
b
% GATE (OPENI THREE WAY
-)(= GATE (CLOSED)
% STOP CHECK (OPEN)
% GLOBE Q STOP CHECK (CLOSED)
% GLOBE (STOP CHECK)
N CHECK h
NEEDLE
-DH SUTTERFLY (DAMPER)
MOTOR OPERATED GLAND LEAK-OFF C
_a_
.,R PERATE.
-yx-
.L O.,..LL M FLOW CONTROL.
% SAUNDER'S TYPE 8e DIAPHRAGM
-+
QUICK HAND OPERATED p SA,m.,REuEP
- e - OATEioOo m DI.K, a
ANGLE 4h SOLENOID f
O.
D 6
-w-
Exhibit 2 (Continued) 5-11 Graphics Attachment (fr~s VALVE SYMBOLS i
'\\
(_/
SQU18 ACTUATED SHEAR PLUG SPECIAL ANGLE (SIPHON)
GLOSE **Y" PATTERN
- DE ENERGlZED NEXT PORT-0F CLOSUAE ENERGlZED GLAND SEAL WATER a.
4@ FLOAT i
d 1F h DIAPHRAGM OPERATED CONTROL (OPENS ON AIR FAILURS)
O
[
d AH DIAPHRAGM OPERATED CONTROL (CLOSEa ON AIR FAILURD MANUAL REMOTE MANUAL OVER RIDE
, 4 h MANUALTRIP & RESET,
M EXCESS FLOW CHECK 1
O e
j
Exhibit 2 (Continurd) 5-12 Graphics Attachment
/,
,1.
MISCELLANEOUS DEVICES L./
@ REDUCER. INCRCASER FILTER
-H0F-exa^asioa smar
- i}- me
\\
M FLEXIBLE CONNECTION FLOW METER (POSITIVE D!SPLACEMENT) 4 EDUCTOR
] THREADED CAP
% AIR EJECTOR
[ QU!CK DISCONNECT f.
OH (sASKET STKAINER
H SASKT( STRAINER
-- E HOSE CONNECTION l
v (DUPLEX) h RUPTURE DISC SPOOL PIECE l
- Y** YYPE STRAINER
& ' h SPECTACLE FLANGE O
Exhihit2(Centinued)~
5-13 Graphi::Attadhment I,
LINE CODING i
1
\\_.
MAIN PROCESS LINE AUXILIARY PROCESS UNE AND INSTRUMENT UNE INSTRUMENT AIR UNE ff ff ff ff ff INSTRUMENT ELECTRICAL LEADS X
X X
fM X~ INSTRUMENT CAPILLAnY TUBING
~
AREA BOUNDARIES
)
SH283 f- -
TERMINAL ARROW FROM OR TO SH 2-C-4
(
100 0 001 )
ARROW FROM OR TO J
{ A1-4 )
LINE SIZE Er CLASSIFICATION
'LSYS.No.
L PIPE CLASS PIPE SIZE
.Q l
G
- - - - - ~ ~ - - -
OxB1@iG M (CEoaGinu20)
~~ 5-14
~
~ ~ ~ ~
^ ~ ~ ~ ~ ~
~
~
~
MISCELLANEOUS DEVICES Graphics Attachment
- p
= HEAT EXCHANGE 5
=
'w/
~
)
HEAT EXCHANGEA (DOUBLE TUBE)
O y
DIAPHRAGM TANK
-[ec
- j STEAM GENERATOR V
m PRESSURIZER V
O e
m
(E51' bit 2-(Cdntinued) 5-15
' i ---
Graphics Attachment n.
I c
'a PUMPS a
N;
\\j
_(
)
CENTRirUGAL PUMP I
. SMALL CANNED MOTOR PUMP
.]
O raN. ='OwEa. OR COMPRESSOR POSITIVE DISPLACEMENT PUMP REACTOR COOLING PUMP l
d b
L-J i
l..
l l
~
~ ~~
~
~
l Exhibit 2(Continued) 5-16 Graphics Attachment ELECTRICAL /lNSTRUMENTS
\\
[
CONVERTER REMOTE OR (CURRENT PNEUMATICI LOCAL PANEL
~
T xP MAIN CONTROL ROOM MULTI POINT RECORDER
~
1 ALARM '
' ELECTRONIC TRIP UNIT N
HIGH USED WHEN SERVICE p
IS DEFINED RM h
COMPUTER SIGNAL g
(Ay LOGIC 3g3 LOCAL GENERATOR
^
BREAKER TRANSMITTER
/9 O OPEN LIGHT TRANSFORMER c
CLOSED D
~
E BATTERY enum O
p_
r___,_,.7,
~.y,__
,_w,,
.__,,,,,,,_,,,p,
._-.--,.9__
--wp
~ g,.
1-mQm Exhibit 3 NUCLEAR RECULATORY COMMIS$10N f
. vow.o.c.sesas-g
~
F;bruary 15, 1986
~
e....-
{,-.
/T
,,Y MEMORANDUM FOR:
Victor Stello, Jr., Acting Esecutive Director for Operations FROM:
Frederick J. Hebdon, Leader Rancho Seco Incident Investigation Team
SUBJECT:
TRANSMITTAL OF THE TEAM'S REPORT CONCERNING THE LOSS OF INTEGRATED CONTROL. SYSTEM POWEP AND DVEPC00 LING TRANSIENT AT RANCHO SECO ON DECEMBER 26, 1985
{
Enclosed for your infonnation and appropriate followup action is the Team's reportMich documents the circumstances and probable causes of the loss of integrated control system power and overcooling transient that occurred at j
t Rancho Seco on December 26, 1985. The Team's report discusses the ma.ior implications of the event and includes the Team's findings and conclusions.
It is our understanding that you will take,appr6priate actions on the P
-important matters contained in the Team's report. Thus, with this report and I
ji subsequent appropriate briefings, the work of the Team will be ccepleted. The b5 enclosed report is an advance copy of NUREG-II95, which will be released (v) publicly at the time of the Comission briefing now scheduled for Tuesday.
February 25,.1986.
.p l
If I can provide any additional information or clarification regarding the Team's report or activities, please let one know.
I bad l
Frederick J. Hebdon, IIT Leader Rancho Seco Incident Investigation Team
Enclosure:
As steted i
cc w/enclostere:
Chairman Palladino Comissioner Roberts Comissioner Asselstine Comissioner 8ernthal Comissioner Zech O
l t
=
i c
.......................~~...............-...-~....~....~~k.~~~~.m.wrnsm*m"*******%T" m
~ - -
Eg.
. j un.Je t.5 lCorstinued_1,
5-l'8 ~
. Le o >
n
. '. 01STRIBUTION w/ enclosure g, goe, may T. Rehn..A0/E00
( [-m.
'i-J. Snierek, DEDR0GR
\\'"j H. Denten, NRR J. Taylor. IE R. Hinogue,'RES J. Davis, W.S$
Regional Administrators D. Eisenhut MRR R. Vollmer IE C. J.'Heltemes, Jr., AE00 C. Kammerer. CA G. Cunningham, ELD J. Fouchard, PA E. Jordan, IE G. Holahan NRA R. Fraley, ACRS l
5.~ 1tiner NP.R G. Edison, IIT N. Sailey, IIT J. T. Seard IIT N. Eaton, IIT F.. Heb&n. JIT M
-.<p
('
g.
1 L
i N
l
. _ _