ML20207D354
| ML20207D354 | |
| Person / Time | |
|---|---|
| Site: | Trojan File:Portland General Electric icon.png |
| Issue date: | 12/23/1986 |
| From: | Brown G, Fish R, Good G, Prendergast K, Tenbrook W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML20207D345 | List: |
| References | |
| 50-344-86-41, NUDOCS 8612300384 | |
| Download: ML20207D354 (11) | |
See also: IR 05000344/1986041
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U.S. NUCLEAR REGULATORY COMMISSION
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REGION V
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Report No.
50-344/86-41
Docket No. 50-344
License No. NPF-1
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Licensee:
Portland General Electric Company
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121 S.W. Salmon Street
Portland, Oregon 97204
Facility Name: Trojan
Inspection At: Rainier, Oregon-
Inspection Conducted:
November 17-21, 1986
Inspectors:
hr)
Ad
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K. M. Prendergast, Easdrgency Preparedness
Date Sigried
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Analyst
ND.
84AC
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, Gobd,(Emergency Preparedness Analyst
Date Signed
Edd_ -A
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G. A. Brown, Emergency Preparedness Analyst
Dat'e Signed
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W. K. TenBrook, Emergency Preparedness
Date Signed
Analyst
Team Members:
F. L. McManus, Comex
L. K Cohen, U.S. NRC
Approved By:
/JL/23 d
R. F. Fish, Chief, Emergency Preparedness
Dath S gned
Section
Sununa ry:
Inspection on November 17-21, 1986 (Report No. 50-344/86-41)
Areas Inspected: Announced inspection of the emergency preparedness
exercise, associated licensee critiques, and followup on corrective actions
resulting from previous inspections.
Inspection procedures 82301 and 92701
were covered.
Results: No violations of NRC requirements were identified.
Several
problems related to demonstrating the ability of the emergency response
organization to respond to an emergency were observed and a remedial
exercise may be necessary.
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DETAILS
1.
Persons Contacted
Portland General Electric Company
J. Lentsch, Manager Nuclear Safety and Regulation
J. Reid, Manager Plant Services
T. Walt, Manager, Radiological Safety
A. Olmstead, Manager of Quality Assurance
B. Sussee, Trojan Operations Supervisor
R. Sherman, Nuclear Engineer
J. Thale, Senior Nuclear Engineer
D. Farrell, Nuclear Quality Assurance Engineer
J. Benjamin, Nuclear Engineer
G. Stein, Event Analysis Engineer
Others
H. Moomey, Oregon Department of Energy
- Indicates those present at the exit interview.
2.
Licensee Action On Previous Inspection Findings
(Closed) 85-28-01:
Revise implementing procedure EP-1, Table 1-4, to
meet NUREG-0654 guidance. Table 1-4 of EP-1 (Classification), revision
10, was reviewed and the unidentified reactor coolant leakage wording
has been changed to reflect the guidance contained in NUREG-0654. This
item is considered closed.
(Closed) 85-28-02:
Include formal logkeeping as an exercise objective
for 1986.
Formal logkeeping was included as an exercise objective for
the 1986 annual emergency preparedness exercise. This item is considered
closed.
{ Closed) 85-28-04:
Raview licensee's evaluation of the adequacy of the
OSC. The licensee determined that the OSC facility was inadequate to
perform its mission during an emergency and a new OSC was established at
the 45 foot level of the Control Building. This item is considered
closed.
(Closed) 85-28-07:
Review short term changes to increase the
effectiveness of the EOF. The licensee has established a new EOF in a
different location of the Visitor Center to meet the requirements of
NUREG-0737. The new EOF was used during the exercise. This item is
considered closed.
3.
Emergency _ Preparedness Exercise Planning
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The licensee's Radiological Engineering Branch (REB) has the overall
responsibility for developing, conducting and evaluating the emergency
preparedness exercise. A member of the REB was assigned to act as a
lead controller with the responsibility of developing the scenario
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package and conducting the exercise. The scenario package was developed
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with the assistance of licensee staff possessing appropriate expertise
(e.g., reactor operations, health physics, engineering). Persons
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involved in the scenario development were not participants in the
exercise.
The REB, in concert with appropriate licensee staff, generated the
exercise objectives and the scenario package. NRC, Region V, was
provided with an opportunity to comment on the proposed objectives and
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the scenario package. The review of the October 3, 1986 scenario package
determined some improvements were necessary. These improvements were
received by Region V on November 6, 1986. The final scenario package
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included the exercise objectives and limitations, player information,
guidelines, scenario messages, plant parameters, meteorological and
radiological parameters, controller instructions and work sheets. The
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exercise document was tightly controlled before the exercise. Advance
ceples of the scenario package were provided to the NRC and other
persons having a specific need. The players did not have access to the
exercise document or information on the scenario events. The exercise
was intended to meet the requirenents of IV.F.2 of Appendix E to 10 CFR Part 50.
Controller / Evaluators were stationed at each of the licensee's Emergency
Response Facilities (ERFs), i.e., Control Room (CR), Technical Support
Center (TSC), Operations Support Center (OSC), and the Emergency
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Operations Facility (EOF)'.
Controllers / Evaluators were also dispatched
with inplant teams. The final briefing of controllers was conducted on
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November 20, 1986. The contents of the exercise package and the
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scenario were discussed with the controller / evaluators and the NRC
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during this meeting.
4.
Exercise Scenario
The exercise scentario began with an event classified as an unusual event
(UE) and ultimately escalated to a general emergency classification
(GE). Milestoac events were as follows:
Classification
Event
Unusual Event
40 percent load rejection resulting in "B"
and "C" pressure safety valves lifting,
however, the "C" safety failed to rescat.
Alert
Primary to secondary leakage greater than
60 gpm.
Loose parts monitor alarms, rnetal
objects in reactor coolant system results
in a 10 percent gap release.
Site Area Emergency /
Major steam generator tube rupture occurs,
General Emergency
3 tubes severed, resulting in about 3500
gpm primary to secondary leakage.
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Significant release via the stuck open
pressure safety valve.
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Federal Evaluators ,
Six NRC inspectors evaluated the licensee's response to the exercise
scenario. . Inspectors were stationed in the CR, TSC, OSC, and EOF. The
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NRC inspectors (3) assigned to the OSC also observed repair / monitoring
teams and a post accident sample system (PASS) team.
A FEMA official was also present in the EOF during the exercise;
however, the exercise was not evaluated by FEMA.
6.
Medical Drill
The licensee held a medical drill on November 18, 1986, the day before
the exercise. The NRC observed this drill. The onsite and offsite
portions of the medical drill were evaluated and the response of the
medical team appeared to be as expected. The responders treated medical
symptoms first and did not allow radiological concerns (contamination)
to interfere with first aid priorities.
It is suggested that more free
play in the initial response would be beneficial.
It was difficult to
evaluate the total medical / radiological response because of the extent
of radiological simulation at the injury site and the controller
provided the patient history and vital signs without them being
requested.
7.
Control Room (CR)
The Control Room crew's abilities to detect and classify emergency
events, analyze plant conditions, take corrective actions to mitigate
the accident, make timely and correct notifications, and formulate
protective actions were evaluated. The following are NRC observations
of the activities in the CR. The "open" item is of sufficient
importance to warrant NRC examination during a future inspection.
a.
The Shif t Supervisor (SS) Limited his ability to demonstrate
command and control by performing administrative duties that could
have been delegated.
Because the SS was involved in the
administrative details, the handling of the "UE" overlapped with
the " alert" event. The SS was still filling out the unusual event
notification form when he was prompted by a controller to declare
an " alert" based upon reactor coolant system leakage greater than
50 gallons per minute,
b.
Due to problems associated with addressing the "UE", the initial
notification of state and local agencies was for the " alert" event
rather than the "UE".
In addition, the notification of these
offsite agencies and the NRC (via the emergency notification
system) was inaccurate in that it stated there was no release
occurring, when in fact there was a small monitored release from
the condenser air ejector vent.
Based upon these observations, it does not appear that the exercise
objectives of demonstrating the ability to classify events and
complete initial notifications in a timely manner were met.
In
addition, the objective of demonstrating effective communication
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with the "0SC" does not appear to have been fully met.
(See
Item h. of paragraph 9 below). Region V will track the licensee's
corrective action (s) related to these CR inadequacies as an "open"
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item (86-41-01).
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8.
Technical Support [ Center (TSC)
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The TSC staff's ability to activate in a timely manner, assess and
classify the accident, formulate protective action recommendations,
perform timely notifications, determine TSC habitability, and support
the CR in its efforts to mitigate the consequences of the accident were
evaluated. The following are NRC observations of the activitier in the
TSC. The "open" items are of sufficient importance to warrant NRC
examination during a future inspection. The other observations are
intended to be suggestions for improving the program,
a.
The engineering group in the TSC was preoccupied with reviewing
data for protective action recommendations and accident
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classification, to the exclusion of efforts to support the control
room and mitigate the accident. This indicates a need for better
management direction of the TSC functions. Region V intends to
track the licensee's related corrective action as an "open" item
(86-41-02),
b.
The TSC failed to adequately perform dose assessment in a timely
manner.
Individuals were observed starting to perform dose
assessment at 9:50 a.m.
They completed the dose assessment at
10:30 a.m.
However, at 10:35 a.m. an error with the dose
assessment was noted, due to the incorrect entry of the delta
temperature. The following two items also contributed to the
problem in dose assessment.
(1) The TSC was not on the list to get updated revisions to the
dose assessment software. Consequently, the dose assessment
software used during the exercise was not a current revision
and was not compatibic with the current procedure.
(2) The licensee has not identified a specific computer in the TSC
to be used for making calculations. This resulted in a
mismatch between the software and the computer during the
exercise.
Region V intends to track the licensce's corrective actions related
to the TSC dose assessment capability as an "open" item (86-41-03).
c.
Logs being kept by the key TSC personnel were only partially
maintained,
d.
Some status board information was not maintained. The times and
dates of plant status and meteorology data were not maintained.
Dose assessment information from the EOF and the TSC, was not
filled in.
Protective action recommendations (PARS) were not
recorded and the status board did not address the liquid release.
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9.
Operations Support Center (OSC)
The following OSC operations were observed:
activation of the facility,
functional capabilities, the disposition of various inplant teams, and
coordination with the CR and the TSC. The following are NRC
observations of OSC activities. The "open" item is of sufficient
importance to warrant NRC examination during a future inspection.
a.
Check off procedures were effectively used during the collection
and analysis of post accident sampling system (PASS) samples.
b.
PASS chemists demonstrated good contamination control practices in
the sample collection and hot laboratory areas.
c.
Controls to prevent the OSC from being contaminated were
inadequate. No barriers or control points were established at or
around the OSC.
Potentially contaminated team members returning to
the OSC entered all areas of the facility without first surveying
themselves for contamination. Step off pads were not set up and
controlled areas were not defined by appropriate (radiological)
posting. No posting was established at the OSC entrance to the
Turbine Building to warn personnel that the Turbine Building was an
airborne radiation area, even though such an announcement had been
made over the public address system. About 3.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> of the
exercise had transpired before the need to establish controls for
preventing contamination of the OSC was recognized,
d.
IIabitability surveys were not conducted until 11:07 a.m.
At this
time the OSC was already extensively contaminated.
Some deficiencies in the proper donning of protective clothing were
e.
observed,
f.
Two qualified persons wearing self contained breathing apparatus
(SCBAs) were unable to operate the equipment.
In Item b.7 of
paragraph 11 below, the licensee acknowledged 14 out of 15 persons
had problems with operating the SCBAs.
g.
The evacuation of the OSC to the alternate OSC located on the floor
below the TSC, could have resulted in contamination of a portion of
the TSC. Surveys at the entrance to the TSC were quickly
discontinued in order to move personnel to the computer area, which
is a shielded location. Neither the evacuation of the OSC
personnel to the alternate OSC, nor the return of teams to the OSC
considered or demonstrated decontamination of personnel.
No role
till was made in the computer area to determine that all personnel
had arrived.
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h.
On at least two occasions the CR and the OSC both sent teams to
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perform the same task. This appears to indicate a lack of
coordination and management of personnel,
i.
Formalized briefings were not held in the OSC.
This resulted in
the radiological protection personnel at times not being aware of
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plant st'atus and the OSC' Director and Maintenance Coordinator
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functioning without the knowledge of the radiological conditions in
the plant. .There also appeared to be delays in transmitting plant
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status information from the CR/TSC to the OSC, e.g., the OSC
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learned of the primary to secondary leak at 10:13 a.m. (58 minutes
after the leakage started) and an operator from the CR incidentally
mentioned that blowdown had been isolated, which conflicted with
information in the OSC at the time.
J.
There appeared to be no formal system (e.g., status board) for
tracking repair / monitoring teams dispatched from the OSC. The
Maintenance Coordinator initiated an informal log to track the
teams, but discontinued it when the scenario events increased in
action. This resulted in persons responsible for tracking teams
not knowing the. team composition at all times.
k.
Team briefings and debriefings were not effective.
Briefing forms
were completed during parts of the briefings rather than completed
before hand and used to conduct the briefing. Briefings were
conducted in stages as the team was assembled, which resulted in
some team members not receiving all of the briefing information.
Also, the briefings did not always include a discussion of exposure
history for team mensbers.
1.
There appeared to be instances where important safety information
on changing plant status cannot be transmitted to teams within the
plant. There are areas in the plant where the public address
system cannot be heard and the teams are not provided with hand
held radios,
m.
The plant status board was not maintained on an up to date basis.
Also, the event classification was not shown.
n.
Examples of personnel making fun of contamination surveys and
joking during the exercise were observed. A lack of concern about
contamination of personnel and the OSC by some individuals was also
noted.
The door to an electrical panel, located just inside the main steam
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support structure, was left open when personnel wearing SCBAs
exited the area due to diminished air supply in their tanks. This
represented a possible safety hazzard.
Based on the above observations, the OSC does not appear to have
satisfactorily demonstrated many of its objectives that were intended to
show an ability to perform the assigned functions. Region V will track
the licensee's related corrective actions as an "open" item (86-41-04).
10.
Emergency Operatto_ns Facility _(EOF)
The following EOF operations were observed: activation and operation of
the facility, of fsite dose assessment and interface with state and local
officials. The following are NRC observations of the EOF activities.
The "open" item is of sufficient importance to warrant NRC examination
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during a future inspection. The last two observations are intended to
be suggestions for improving your program,
A personnel " frisking" station was established in a timely manner
a.
at the entrance to the Visitors Center to prevent contamination of
the EOF. Habitability surveys were initiated as soon as conditions
warranted it,
b.
Guards were stationed at the entrances to the Visitors Center and
the EOF to control personnel entering these areas.
c.
Field monitoring teams were moved in a timely manner when the wind
direction changed,
d.
The Dose Assessment Director took appropriate action when a
radiation level that appeared to be erroneous was reported by a
field team.
e.
Approximately two hours af ter the declaration of an " alert," the
EOF was declared operational and the Emergency Response Manager
assumed the responsibilities of the Emergency Coordinator. The EOF
had been declared " activated" nine minutes af ter the declaration of
the " alert", which meant the facility was capable of offsite
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communications and performing dose assessments.
The delay in
declaring the facility operational resulted in all event
classifications, protective action recommendations and verbal
notifications to the offsite authorities being made by the TSC,
consequently hampering the operation of the TSC. Thus, the EOF did
not demonstrate during this exercise that these nondelegable
responsibilities could be performed.
Taking 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> to declare the EOF operational is not consistent
with the guidance in Supplement 1 to NUREG-0737 (Tabic 2). The E0F
Director / Senior Manager is expected to be in the EOF within about
sixty (60) minutes. This is the same time frame for staffing the
EOF to assume its assigned responsibilities (reference NUREG-0654
and NUREG-0696). Region V intends to track the licensee's actions
to address the timely activation of the EOF as an "open" item
(86-41-05).
f.
The EOF staff was not informed that the facility had been
activated. The EOF Director did record this information in the log
book. However, because the Security Director was unaware that the
EOF was activated, during one telephone call, he incorrectly stated
that the EOF was not activated.
g.
The initial dose calculation took about 40 minutes to perform.
If
dose assessment is necessary in order to make protective action
recommendations, considerable improvement will be required in order
to meet the fifteen minute requirement in IV. D. 3. of Appendix E
to 10 CFR 50.
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11. Exercise Critiques
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Inusediately af ter the exercise, informal critiques were held in each of
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the emergency response facilities. A formal licensee critique was held
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on November 20, 1986, the day following the exercise. The purpose of
this critique was to summarize the findings of the exercise and to
discuss weaknesses or deficiencies identified during the exercise. The
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following represent some of the licensee's findings discussed during
this meeting,
a.
Control Room
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(1) The CR failed to classify the event in a
timely manner.
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(2) Plant personnel had trouble following some of the new
procedures that were issued just prior to the exercise. As an
example, the logic diagram in EP-1 was hard to follow.
(3) The OSC's requesting information from the CR interfered wit.h
the SS's or the Assistant SS's ability to perform their normal
CR responsibilities. An extra communicator is suggested to
help with communication to the OSC.
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Operations Support Center
(1) The OSC was set up before the alert was declared.
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(2) The new OSC is too noisy.
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(3) The new OSC needs to establish an area to dispatch personnel.
(4) No radios were availabic for OSC personnel.
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(3) The new OSC lacked sufficient reference materials, e.g., p and
ids, I and C procedures, technical manuals etc.
(6) Data flow problems from the CR to the OSC were experienced.
(7) A significant number of individuals were inexperienced in the
operation of the SCBAs. Fourteen out of fifteen personnel
experienced problems in the operation of the SCBAs.
It should
be noted that these were qualified individuals.
(8) Radiation Protection was unable to set up barriers due to a
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lack of technicians. Radiation Protection may be underntaffed
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to respond to an emergency. No barriers were set up in the
Turbine Building to keep the OSC habitable.
No air samples
were taken in the main steam support or Turbine Building areas
to determine necessary protective measures.
(9) Contamination was out of control in the OSC.
In addition, the
CR may have been contaminated by OSC personnel.
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(10) No concern was exhibited over the contamination of SCBAs.
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Used SCBA air tanks, were mixed with full ones. Other
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problems, including trying to refill full tanks, were noted.
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(11) The Public Address system was not audible in all areas and
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there was.no method to contact inplant teams. Tl.ere were no
radios availabic in the OSC.
(12) Cosusunications between repair / monitoring teams were poor. OSC
personnel were' unaware of the location of field teams until
they returned.
(13) The OSC evacuation was poorly managed. All personnel were not
aware of the evacuation of the OSC.
(14) The technicians in the OSC did not know the big picture of
what was happenhg. The OSC was net aware of the wind shift
or the primary to secondary leakage experienced in the
scenario.
(15) There was duplicated effort between the CR and the OSC. This
led to the question of who do they (the teams) report back to,
c.
(1) Hard copy transmission problems were experienced between the
EOF and the Oregon Department of Energy.
(2) The Coast Guard was not notified of the radioactive liquid
release to the river.
(3) Numerous problems were experienced with the phones in the EOF.
Some were too loud and it was difficult to tell which phones
were ringing. A light for the phones was suggested.
12. F.xit interview
An exit interview was held on November 21, 1986.
Licensee
representatives present during the exit interview have been identified
in Paragraph 1 above. The NRC was represented by the six evaluator team
members and the NRC Resident Inspector.
During this meeting the
licensee was informed of the preliminary results of this inspection, as
described in Paragraphs 6 through 10 above, and that these findings are
subject to discussion and approval by regional management.
There were no violations of NRC requirements specifically identified
during this inspection. There were, however, a large number of problems
observed that warrant corrective action.
The possibility of the NRC
requesting a remedial exercise was also mentioned.
Concern was expressed over the number of radiological safety problems
observed in the OSC and the need for improved management in emergency
response facilitics. The Itcensee also expressed dissatisfaction over
the performance of the OSC and stated that they were considering another
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drill to demonstrate improved performance. The licensee also requested
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an opportunity to participate in discussions with regional management
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concerning whether a remedial exercise is to be required and ,its scope.
Subsequent to the exit interview, the licensee informed the Regional
0ffice that they were forming an independent audit group to review the
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exercise findings and determine the root cause of the poor performance
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during the exercise. The make up of the audit group was noted to
include members who are not part of the Portland General Electric
organization.
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