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Insp Rept 50-344/86-41 on 861117-21.No Violations Noted. Major Areas Inspected:Emergency Preparedness Exercise, Associated Licensee Critiques & Followup on Corrective Actions Resulting from Previous Insps
	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:	;
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ML20207D345	List: ML20207D343; ML20207D354;
References
	50-344-86-41, NUDOCS 8612300384
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,f- U.S. NUCLEAR REGULATORY COMMISSION

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REGION V

Report No. 50-344/86-41

Docket No. 50-344

License No. NPF-1

! Licensee: Portland General Electric Company

l 121 S.W. Salmon Street

Portland, Oregon 97204

Facility Name: Trojan

Inspection At: Rainier, Oregon-

Inspection Conducted: November 17-21, 1986

Inspectors: hr) Ad #2/131 %

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K. M. Prendergast, Easdrgency Preparedness Date Sigried

Analyst

ND. 84AC 3 D/23lWo

G , Gobd,(Emergency Preparedness Analyst Date Signed

Edd_ -A

G. A. Brown, Emergency Preparedness Analyst

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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

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(e.g., reactor operations, health physics, engineering). Persons

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

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with inplant teams. The final briefing of controllers was conducted on

l November 20, 1986. The contents of the exercise package and the

! scenario were discussed with the controller / evaluators and the NRC

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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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5. Federal Evaluators ,

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Six NRC inspectors evaluated the licensee's response to the exercise

scenario. . Inspectors were stationed in the CR, TSC, OSC, and EOF. The

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

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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)

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

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data for protective action recommendations and accident

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 0.00139 hours 8.267196e-6 weeks 1.9025e-6 months 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.

e. Some deficiencies in the proper donning of protective clothing were

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.

i h. On at least two occasions the CR and the OSC both sent teams to

l 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

functioning without the knowledge of the radiological conditions in

the plant. .There also appeared to be delays in transmitting plant

j , status information from the CR/TSC to the OSC, e.g., the OSC

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.

o. The door to an electrical panel, located just inside the main steam

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. A personnel " frisking" station was established in a timely manner

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 ,

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 5.555556e-4 hours 3.306878e-6 weeks 7.61e-7 months 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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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

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

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.

(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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b. 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.

l (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 r

lack of technicians. Radiation Protection may be underntaffed '

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.

. Used SCBA air tanks, were mixed with full ones. Other

problems, including trying to refill full tanks, were noted.

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The Public Address system was not audible in all areas and

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. Emergency Operations Facility

(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 i

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an opportunity to participate in discussions with regional management

concerning whether a remedial exercise is to be required and ,its scope.

Subsequent to the exit interview, the licensee informed the Regional

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exercise findings and determine the root cause of the poor performance

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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ML20207D354

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