ML20216D323
| ML20216D323 | |
| Person / Time | |
|---|---|
| Issue date: | 09/05/1997 |
| From: | Advisory Committee on Reactor Safeguards |
| To: | |
| References | |
| ACRS-T-3010, NUDOCS 9709090286 | |
| Download: ML20216D323 (127) | |
Text
.
Official Transcript cf Proceedings O
NUCLEAR REGULATORY COMMISSION ACRST-Bolo
Title:
Advisory Committee on Reactor Safeguards 444th Meeting TRO4 (ACRS)
RETURN ORIGINAL TO BJWHITE Docket Number:
(not applicable) y(Sg2E2s THANKS!
Location:
Rockville, Maryland O
Date:
Friday, September 5,1997 A3RS Tce Copy-Rets-fc:the L.;fe of the Dom 0::ee Work Order No.:
NRC-1228 Pages 495-588
\\\\lIIIIlII\\IEllf\\\\l[lllj\\\\l]lllll\\
NEAL R. GROSS AND CO., INC.
G a 7 P r f)
Court Reporters and Transcribers h
J{'ffIQIf e 1323 Rhode Island Avenue, N.W.
g l( p.
Washington, D.C. 20005 (202) 234-4433 g 90 g 6 970905 T-3010 PDR
,m DI8 CLAIMER PUBLIC NOTICE BY THE UNITED STATES NUCLEAR REGULATORY COMMISSION'S ADVISORY COMMITTEE ON REACTOR SAFEGUARDS SEPTEMBER 5, 1997 The contents of this transcript of the proceedings of the United States Nuclear Regulatory Commission's Advisory Committee on Reactor Safeguards on i
SEPTEMBER 5, 1997, as reported herein, is a record of the discussions recorded at the meeting held on the above date.
This transcript has not been reviewed, corrected and edited and it may contain inaccuracies.
^'r)
NEAL R. GROSS COURT REPORTERS ANDTRANSCRIBERS 1323 RilODE ISLAND AVENUE, NW (202)234-443 p WA51tINGTON, D C. 20003 (202)234-4433
495 I
UNITED STATES OF AMERICA 2
NUCLEAR REGULATORY COMMISSION
,ml
)
' s_ '
3
+ + ++ +
4 ADVISORY COMMITTEE ON REACTOR SAFEGUARDS 5
444th MEETING 6
++ +++
7 FRIDAY 8
SEPTEMBER 5, 1997 9
+ ++ ++
10 ROCKVILLE, MARYLAND 11 12 The Advisory Committee met at the Nuclear 13 Regulatory Commission, Two White Flint North, Room T2B3,
(.
()
14 11545 Rockville Pike, at 8:30 a.m.,
Robert L.
- Seale, 15 Chairman, presiding.
16 COMMITTEE MEMBERS:
17 ROBERT L.
SEALE CHAIRMAN 18 DANA A.
POWERS VICE CHAIRMAN 19 GEORGE E, APOSTOLAKIS MEMBER 20 JOHN J. BARTON MEMBER 21 MARIO FONTANA MEMBER 22 THOMAS S.
KRESS MEMBER 23 DON W. MILLER MEMBER 24 WILLIAM J.
SHACK r4 EMBER
,n w) 25 ROBERT E.
UHRIG MEMBER NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W.
(202) 234-4433 WASHINGTON, D.C. 20005-3701 (202) 234-4433
496 1
ACRS STAFF PRESENT:
2 JOHN T.
LARKINS Exec. Director 7,
('~'
3 RICHARD P.
SAVIO Dep. Exec. Dir.
4 ROXANNE SUMMERS Tech. Secretary 5
SAM DURAISWAMY 6
CAROL A. HARRIS 7
PAUL BOEHNERT 8
NOEL DUDLEY 9
AMARJIT SINGH 10 MEDHAT M. EL-ZEFTAWY 11 MICHAEL T. MARKLEY 12 ALSO PRESENT:
13 ROBERT L.
DEhWIG r\\
%s 14 MARK L.
DAPAS 15 GEOFFREY C.
WRIGHT 16 GREG S. GALLETTI 17 JOE EENIGENBURG 18 MIKE LYON 19 CECIL THOMAS 20 JAY PERSENSKY 21 22 23 24 t,
,t 25 NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4 3 WASHINGTON, D C 20005-3701 (202) 234-4433
4971 1
A-G-E-N-D-A 2
Acenda Item Pace fq N]
3 Opening Remarks by ACRS Chairman 498 4
Improper Control Rod Movement During 5
Shutdown at Zien Unit 1,
and 6
Nonconservative Operations During 7
Isolation of Recirculation Pump Seal 8
Leak at Clinton 9
John Barton - Subco.,mittee Chair 499 10 Robert Dennig 501 11 Mark Dapas 502 12 Geoffrey' Wright 552 13 Mike Lyon 565 (O
14 Greg Galletti 566 15 16 17 18 19 20 21 22 23 24
,-m.
N_,,)
25 NEAL R. GROSS 4
COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
498 1
P-R-0-C-E-E-D-I-N-G-S 2
(8:34 a.m.)
7-s 3
CHAIRMAN SEALE:
The meeting will now come to 4
order.
This is the third day of the 444th Meeting of the 5
Advisory Committee on Reactor Safeguards.
During today's 6
meeting the committee will consider the following:
7 (1) Operating events involving improper 8
control rod movement during shutdown at Zion Unit 1, and 9
nonconservative operations during isolation of 10 recirculation pump seal leak at the Clinton Nuclear Plant; 11 (2) Reconciliation of ACRS comments and 12 recommendations; 13 (3) Report of the Planning and Procedures (h
\\
~/
14 subcommittee; and 15 (4) preparation of reports.
16 Looking at the list up there, I have to count 17 at least seven -- and I know there are a couple of things 18 between the lines -- so we've got a busy day today.
I 19 hope we will judge our comments accordingly.
20 Portions of today's meeting may be closed to 21 discuss organizational and personnel matters that relate 22 solely to the internal personnel rules and practices of 23 this advisory committee and matters, the release of which, 24 would represent a clearly unwarranted invasion of personal p
25 privacy.
NFJtL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON D C. 20005-3701 (202) 234 4433
499 1
Thic meeting is being conducted in accordance 2
with the provisions of the Federal Advisory Committee Act.
7s
)
3 Mr. Sam Duraiswamy is the designated Federal official for the initial portion of this meeting.
4 5
We have received no written comments or 6
requests for time to make oral statements from members of the public regarding today's sessions.
A t'anscript of
?
8 portions of the meeting is being kept, and x-is requested 9
that the speakers use one of the microphones, identify 10 themselves and speak with sufficient clarity and volume so 11 that they can be readily heard.
12 The first presentation on the events --
i 13 improper control movement at Zion and nonconservative
/
)
\\-)
14 operations during pump seal isolation at Clinton -- John 15 Barton is the subcommittee Chairman for that effort and 16 I'll ask John to introduce our speakers.
It's all yours.
17 MEMBER BARTON:
Thank you, Mr. Chairman.
The 18 purpose of this morning's briefing is to review 19 circumstances surrounding two operational events -- one at 20 the Zion plant and one at Clinton plant -- as Bob Seale l
21 mentioned.
22 In light of the heightened interest on the 23 part of ACRS in human performance factors and management 24 and organizational effectiveness, I believe that the two (7
(,)
25 events selected for briefing today will be interesting to i
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344433 WASHINGTON, D.C. 20005-3701 (202) 234-4433
500 1
the committee in its work it's pursuing along those lines.
2 This is an informational briefing today.
7-3 There is no committee action planned or required at this 4
time.
There are members -- licensees present.
Licensees 5
do not plan to make any presentations but they are here to 6
answer questions and can make comments at the end of the 7
briefing.
8 A little bit of background on these two issues 9
just to bring us up to speed.
In February 1997, a control 10 room operator at Zion improperly inserted control rods 11 into the core taking the reactor suberitical.
And 12 realizing his error, continually withdrew control rods in 13 an attempt to restart the reactor without direction from (D
\\
}
k/
14 shift management.
l 15 And in September 5th of 1996, operators at i
16 Clinton were attempting to place the Unit in a aingle loop 17 operation due to suspected recirc pump seal leakage.
They 18 were trying to go to single loop operation.
And due to 19 ineffective planning and execution, resulted in the 20 operators taking non-conservative actions resulting in 21 seal failure, and it forced Unit shutdown.
22 Both of these events I think, exhibit human 23 performance errors, organizational effectiveness issues, 24 lack of conservative decision-making, and the Zion event 78 i,)
25 is classified in industry also, as a reactivity event --
NEAL R. GROSS COURT REPORTERS ANC TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D.C. 20005-3701 (20 7 234-4433
501 1
something that the industry has been struggling with 2
trying to resolve over the years.
_s 3
So at this point, with that background, I'll 4
turn the meeting over to the NRC staff, to Brian Sheron, 5
who will introduce the presenters.
6 MR. DENNIG:
Hi, this is Bob Dennig, Events 7
Assessment --
8 MEMBER BARTON:
Bob, all right.
9 MR. DENNIG:
-- pinch hitting for Brian 10 Sheron.
Let me just say, we're pleased to provide this 11 informational briefing for the ACRS on the scope as noted.
l l
12 The folks that we have here today to make presentations in 13 support include our presenters Mark Dapas from Region III
()
'x.,/
14 who will be talking about the Zion event.
He was the AIT 15 team leader.
16 We also have Jeff Wright from Region III who 17 has been involved in the preparation of the inspection 18 reports; a very knowledgeable individual on the Clinton 19 issue.
20 And then we also have Greg Galletti from Human 21 Factors Assessment Branch in the Division of Reactor 22 Controls and Human Factors.
He'll be talking some human 23 factor's aspects of the two events.
24 Also we have with us today Lee spessard and (3) 25 Cecil Thomas, the director and deputy director, NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
502 1
respectively, of the Division of Reactor Controls and 2
Human Factors.
We also have support from Projects:
Bob 73)
\\
3 Capra ie here and Gail Marcus.
4 And from the licensees -- we're appreciative 5
that they could attend -- from Illinois Power we have John 6
Cook, site vice president, and Mike Lyon, the ops manager, 7
Syntem plant manager.
8 And from Commonwealth Edison I believe we have 9
just arriving, Joe Eenigenburg, who was on the 10 Commonwealth Edison event investigation team for the event 11 that we're going to discuss.
We also have Leslie Holden l
12 who is a nuclear licensing assistant, and I believe Robert 13 Godley, the Regulatory Assurance supervisor, n
w 14 So with that introduction I'd 2ike to turn it 15 over to our first presenter, Mark Dapas, who is going to 16 talk about the Zion even.
Mark.
17 MR. DAPAS:
Thank you, Robert.
Good morning.
18 My name is Mark Dapas and as Mr. Dennig indicated, I am 19 the acting deputy director for the Division of Reactor 20 Products in Region III, 21 This morning I will be discussing the 22 reactivity management event that occurred at Zion station 23 on February 21st, 1997.
This even involved improper 24 control rod movements by a licensed reactor operator in an
, ~x()
unauthorized attempt to take the reactor critical from a 25 NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D.C. 20005-3701 (202) 234-4433
503 1
shutdown condition.
7- -
2 There were several root causes for this event,
!' ')
3 as noted on the slide.
I will discuss each of these root 4
causes in more detail when I preser the major findings of 5
the augmented inspection team which reviewed the 6
circumstances surrounding the reactivity management event, 7
but first I would like to describe the sequence of events 8
in some detail.
9 Discussing the sequence of events in detail 10 serves to highlight the significant human performance 11 problems that were manifested in this event.
12 on Wednesday, February 19th, at approximately 13 12 p.m.,
during a surveillance test for the 1C contai. ament O\\~)
14 spray pump, the licensee observed that it took an I
15 abnormally long time for the pump to start.
The licensee 16 subsequently declared the 1C containment spray pump 17 inoperable and entered the associated technical 18 specification limiting condition for operation, which 19 required that the containment spray pump be returned to 20 inoperable status within the next 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> or Unit 1 be in 21 hot shutdown within the following four hours.
22 On Friday, February 21st at 4:40 a.m.,
the 23 licensee completed corrective maintenance on the 1C 24 containment spray pump and initiated post-maintenance
/~N
(,)
25 test.
The first start attempt was successful; however, NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344433 WASHINGTON, D.C. 20005-3701 (202) 234-4433
504 1
the pump did not start within the required time on the 2
second start attempt, and the licensee initiated 7si)
3 additional troubleshooting efforts.
4 Later that morning, at 7 o' clock, operating 5
crew 3 began their first day of shift duty after having 6
three days off.
Although the 48-hour limiting condition 7
for operation would expire in less than four hours 8
requiring entry into a 4-hour shutdown action statement, 9
discussion during the shift turnover briefing centered 10 around restoration of the 1C containment spray pump.
No 11 plan had been developed to support an orderly and 12 controlled shutdown of Unit 1, 13 At 9:30 a.m.,
Operations Management discussed
/~~
(_)
14 with senior nuclear engineering supervision the need to 15 conauct a briefing between the nuclear engineers and 16 control room operators regarding reactivity management 17 during the shutdown.
18 When one of the qualified nuclear engineers 19 subsequently contacted the Unit supervisor to arrange a 20 meeting time, both the Unit supervisor and shift engineer 21 stated that they were too busy due to activities in the 22 control room.
23 The qualified nuclear engineer, or QNE, left 24 his pager number with the Unit supervisor and asked that
,~.()
25 he be paged when the Unit supervisor was ready to conduct NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344433 WASHINGTON, D C. 20005-3701 (202) 2344433
505 1
this briefing; however, the briefing was never conducted.
2 At 10:40 a.m.,
the 48-hour limiting condition
~.
- j
\\
3 for operations expired and the licensee entered a 4-hour 4
shutdown action statement for Unit 1.
5 At approximately 11 a.m.,
an informal 6
discussion was held between Plant Management, Operations 7
Management, and Operations Supervision regarding the 8
status of the 1C containment spray pump and when to 9
initiate action to shut down Unit 1.
10 During this discussion, senior licensee 11 management attempted to convey to Operations Supervision 12 that it was acceptable to shut down the Unit, complete 13 testing of the containment spray pump, and then to restart
(
(_,/
14 the Unit.
However, this message was not effectively j
15 communicated.
16 Ten minutes later at 11:10, the unit 17 supervisor conducted a formal shutdown briefing.
Much of 18 this briefing focused on reactivity management such as the 19 use of control rods versus boration remaining with the 20 axial delta flux band and addressing xenon concerns in 21 order to be able to quickly return Unit 1 to higher power, 22 presuming that the containment spray pump would be 23 restored.
24 Despite the discussions with Plant Management r~Ni (J
25 shortly before the formal pre-evolution brief, Operations NEAL R. GROSS court REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234 4433
506 1
Supervision did not provide any direction to the operating 2
crew regarding the decision point for proceeding to hot 7-s
(
)
3 shutdown.
4 At 12:09 p.m.,
control room operators began 5
- .ducing power at a quarter percent per minute.
At 12:14, 6
the licensee notified the NRC about the technical 7
specification required shutdown.
At approximately 12:55, 8
the li'ensee identified through a review of surveillance 9
testing records, that the 1C containment spray pump should 10 have been declared inoperable at 10:20 a.m.
vice 10:40 11 a.m.,
on February 19th.
12 As a result, the licensee was required to be 13 in hot shutdown by 2:20 vice 2:40 p.m.
in order to comply f~'T
(-)
14 with the 4-hour shutdown action statement.
Consequently, l
15 control room operators increased the rate of power 16 reduction to a half-percent per minute.
17 At 25 percent reactor power, operators entered 18 the general operating procedure for a plant shutdown.
At 19 approximately 2:04 p.m.,
with Unit 1 at seven percent 20 power, the shift engineer directed the Unit supervisor to 21 maintain the reactor critical since he expected the 22 containment spray pump to be returned to service within 23 the next few minutes.
24 In directing the Unit supervisor to remain the
(~h
(,)
25 reactor critical, the shift engineer intended to keep Unit NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W.
(202) 234-4433 WASHINGTON, D.C. 20005-3701 (202) 234-4433
507 1
1 in oper;tional Mode 1 -- defined as reactor power 2
greater unan or equal to two percent
-- because he was 7-s i
3 concerned that if Unit 1 was placed in Mode 2 -- defined 4
as a core reactivity condition greater than or equal to 5
zero and power less than or equal to two percent -- Unit 1 6
could not be immediately returned to Modt 1 due to the 7
inoperable status of a hydrogen monitor.
8 The shift engineer's direction to the Unit 9
supervisor was not clear and consequently, the Unit 10 supervisor thought that the shift engineer was directing 11 him to maintain the Unit i reactor in Mode 2, at or below 12 the point of adding heat per the shutdown procedure, f
)
i 13 I'd like to point out that this condition is
()
(_/
14 an authorized condition per the shutdown procedure.
15 The Unit supervisor and primary nuclear Unit 1
16 station operator -- or NSO -- then reviewed the steps in 17 the shutdown procedure for taking the turbine offline and 18 inserting control rods to establish power at or below the 19 point of adding heat, defined as.025 percent power.
20 This review consisted of the Unit supervisor 21 reading the relevant step allowed and requesting the 22 primary nuclear station operator to locate the point on 23 the intermediate power range monitor corresponding to.025 24 percent power.
<~(x) 25 The primary NSO identified this point and then NEAL R. GROSS COURT REPORTERS AND TRANSchlBERS 1323 RHODE ISMND AVE., N W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 2344 433
508 1
asked the Unit superviso<. if he wanted him to drive rods 2
in.
The Unit supervisor responded by re-reading the 7-(J 3
subject procedure step allowed wnich states:
hold number 4
363, rod motion control switch, in to minimize dumping 5
steam and establish power at or less than the point of 6
adding heat -- 2. 5 x 10-2 percent on the intermediate 7
range.
8 At 2:07 p.m.,
the main turbine was tr!pped.
9 The Unit supervisor then read the applicable step allowed 10 to the primary nuclear station operator, and after 11 acknowledging this directive the primary NSO began 12 inserting control rods.
The Unit supervisor left the area 13 where the primary NSO was stationed to addressed balance-l,(m.,,
\\_s/
14 of-plant problems involving the control of feedwater level 15 using a feedwater regulating bypass valve.
\\
16 The qualified nuclear engineer, or QNE, 17 assigned to monitor the Unit i shutdown, observed 18 indication of Control Bank Charlie insertion due to bank 19 overlap, approached the primary nuclear station operator 20 and informed him that the reactor was substantially 21 suber'tical.
22 The primary NSO informed the ONE that he was 23 following 1.1s procedures.
The QNE then left the area 24 where the primary NSO was stationed, to monitor nuclear ID (y
25 instrumentation and rod position indication.
The primary NEAL R. GROSS COURT REPORTERS AND TRANSCRIBdRS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D.C. 20005-3701 (202) 234-4433
509 1
NSO continued to insert control rods for a total of 3 2
minutes and 48 p_ )
seconds until power indicated.025 percent, t
3 About one minute later, with the reactor 4
substantially suberitical and power continuing to decrease 5
due to the large amount of negative reactivity added by 6
the control rods, the primary nuclear station operator 7
informed the Unit supervisor that he intended to withdraw 8
control rods to establish power at.025 percent.
9 The Unit supervisor, who was not cognizant 10 that power had been reduced to.01 percent as a result of l
11 the continuous rod insertion, acknowledged the primary 12 nuclear station operator.
he primary NSO then proceeding 13 to withdraw control rods.
,m
+
\\
(_)
14 I would like to take a minute and explain what 15 control rod manipulation should have occurred.
To 16 establish power at the point of adding heat, the primary 17 nuclear station operator should have inserted control 15 rods, approximately 10 to 15 steps, in order to establish 19 a negative startup rate and then allowed power to coast 20 down to.025 percent.
21 As power approached this point the operator 22 then should have withdrawn control rods only a few steps -
23
- say in the order of two to three steps -- in order to 24 stabilize power at the new level, r^;
I i
25 Getting back to the sequence of events --
x/
s NEAL R. GROSS COURT REPORTERS ANJ TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
510 1
CHAIRMAN SEALE:
Could I ask --
2 MR. DAPAS:
Yes.
, ~s
(
)
'~'
3 CHAIRMAN SEALE:
-- a question?
How hard did 4
he, in fact, insert the rods?
5 MR. DAPAS:
He inserted the rods -- counting 6
both Control Bank Charlie and Delta -- a total of 232 7
steps.
You insert Control --
8 CHAIRMAN SEALE:
Slight overkill, 9
MR. DAPAS:
-- Bank Charlie and then with 10 overlap, Control Bank Delta starts to insert.
And so the 11 total amount of rod insertion was 232 steps over a 3 12 minute and 48 second time period.
l 13 CHAIRMAN SEALE:
Some overkill?
()N
(_
14 MR, DAPAS:
Yes.
And I'd like to point out f
15 that the primary nuclear station operator thought that the 16 intent of the procedure was to insert rods until power 17 indicated.025 percent, versus as I've discussed, 18 inserting rods and allowing power to coast down on the 19 stable start-up rate.
20 CHAIRMAN SEALE:
Okay.
Thank you.
21 MR. DAPAS:
In ic9ponse -- correction -- the 22 QNE observed that the primary NSO was withdrawing control 23 rods, became concerned with the excessive control rod
(
24 manipulations, and discussed this concern with the primary
,n
(
I 25
- NSO, In response to the QNE, the primary NSO stated that MJ NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON. D C. 20005-3701 (202) 2344433
511 1
he was uncomfortable with what he was doing as well, but 2
he was simply following the pro 3 dure.
7-i Y#
3 And I'd like to point out that the primary 4
nuclear station operator thought that he should insert 5
control rods until power indicated.025 percent, and then 6
he realizes that in order to establish power at the point 7
of adding heat, he has to turn around and continually 8
withdraw rods in order to take the reactor critical again.
9 The shift engineer approached the qualified 10 nuclear engineer, who informed the shift engineer of his 11 concern with "up and down control rod manipulations".
The 12 shift engineer did not understand the significance of the 13 qualified nuclear engineer's comment, turned around and
(~h
(-)
14 walked away from the QNE.
15 The primary NSO withdrew control rods 16 continuously for 1 minute and 45 seconds, until he was 17 directed to trip the reactor by the Unit supervisor.
The 18 total rod withdrawal was about 82 steps, if I recall 19 correctly.
20 The Unit supervisor had been instructed to 21 trip the reactor by the shift engineer because the 1C 22 containment spray pump had not been restored and Unit 1 23 had to be in hot shutdown within the next six minutes in 24 order to comply with the technical specifications.
'yp) 25 At 2:15 p.m.
the Unit 1 reactor was manually NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344433 WASHINGTON, D C. 20005-3701 (202) 234-4433
)
512 1
tripped, placing the Unit in hot shutdown.
At 2:37 p.m.,
2 the ONE exited the control room.
At 3:08, the QNE and v' W\\
')
3 lead nuclear engineer discussed their concerns with 4
improper control rod manipulations during the shutdown, 5
with the shift engineer and informed him of their 6
intention to formally identify that the operating crew 7
attempted to restart a shutdown reactor.
8 The shift engineer informed the QNE and lead t
9 nuclear engineer that he was not aware that the reactor
}
10 had been shut down and that the operating crew had 11 attempted to restart the reactor.
12 MEMBER MILLER:
A question.
13 MR. DAPAS:
Yes.
(
)
(_)
14 MEMBER MILLER:
When you use the term 15
" supervisor", I assume that means shift supervisor?
16 MR. DATAS:
Right.
The control room structure L
17 is, you have a primary nuclear station operator at the 18 control panels, a secondary nuclear station operator often 19 involved with balance of plant manipulations, and then you 20 have a Unit supervisor for each Unit -- Zion Station has a 21 Unit 1 and Unit 2 -- and then you have a shift engineer 22 who is in charge of both the Unit supervisor for Unit 1 23 and 2.
24 MEMBER MILLER:
So the shift engineer in this (m) 25 case is b'lically the overall plant supervisor?
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4 433 WASHINGTON, D C, 20005-3701 (202) 2344 433
513 1
MR. DAPAS:
He's responsible for overall 2
command and control.
,,_s
)
\\-
3 MEMBER MILLER:
He's not the shift technical 4
advisor?
5 MR. DAPAS:
No, he is not.
6 MEMBER MILLER:
Okay.
I was just trying to 7
determine all that.
8 MR. DAPAS:
And when I speak about Operations 9
Supervision, I'm including the Unit supervisor and shift 10 engineer.
When I speak about Operations Management I mean 11 the assistant Operations manager and Operations manager.
12 And then Plant Management consists of the plant manager 13 and in some cases, the site vice president.
O 11 CHAIRMAN SEALE:
But the shift engineer has 15 dual Unit responsibility?
16 MR. DAPAS:
Right.
17 CHAIRMAN SEALE:
The Plant or Unit engineer i
18 does not?
19 MR. DAPAS:
The Unit supervisor has 20 responsibility for his assigned Unit.
21 CHAIRMAN SEALE:
Okay.
22 MEMBER MILLER:
So what is the shift technical 23 advisor called at Zion?
24 MR. DAPAS:
Joe, perhaps you could help me out
,r 25 L
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE. N.W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
514 1
MEMBER MILLER:
That's why I said --
2 MR. DAPAS:
I believe one of the Unit gs t
3 supervisors is --
4 MEMBER MILLER:
I kept hearing shift engineer 5
6 MR. DAPAS:
-- the shift technical advisor 7
when there is an event that would require the shift 8
technical engineer's presence, is that correct?
9 MEMBER MILLER:
Because the shift technical 10 advisor should have no control -- just be advised.
That's 11 what's confused me on this.
I understand now the 12 structure.
13 MR. DAPAS:
Yes, I do think some plants have a A
14 Unit supervisor fulfill both duties --
15 MEMBER BARTON:
There's different 16 organizational structures with STA.
Is the STA required 17 to be in the control room, or is the STA off and only 18 comes in the control room if called, at Zion?
19 MR. DAPAS:
I believe it varies.
20 MEMBER BARTON:
But was the STA involved in 21 this event at all?
22 MR. DAPAS:
No.
Although one of the Unit 23 supervisors is the designated STA.
24 MEMBER MILLER:
My only confusion was when you l'h
}
)
25 used the term " shift engineer" I was interpreting that as NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D C, 20005-3701 (202) 234-4433
,g 515 1
2 MR. DAPAS:
No, no.
s
[
h i
/
3 MEMBER MILLER:
And he in no way should be 4
giving these kinds of directions.
5 MR. DAPAS:
No.
The shift engineer is the 6
designated individual responsible for --
7 MEMBER MILLER:
Working on --
8 MR. DAPAS:
-- command and control of the 9
operating crew on both Units.
10 The shift engineer directed the nuclear 11 engineers to discuss the issue with the Unit supervisor, 12 primary NSO, and Unit 1 Operations manager.
Consequently, 13 the nuclear engineers discussed this event with the Unit
/~'N i
s ks/
14 supervisor and primary NSO.
l 15 The Unit supervisor and primary NSO responded 16 to the nuclear engineers by stating that they were 17 adhering to the shutdown procedure.
And I'd like to point 18 out, at this point in time the operating crew did not 19 realize that they had attempted to restart a reactor and 20 didn't understand the significance of the nuclear 21 engineer's concern.
22 At approximately 6 p.m.,
nuclear engineers
- 23. discussed their concerns of improper control rod 24 manipulations with operations Management -- specifically
(
)
25 the assistant operations manager and operations manager --
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344 433 WASHINGTON, O C. 20005-3701 (202) 234 4433 i
516 1
and a preliminary root cause investigation was initiated 2
by the licensee.
7,
('-)
3 At about 8:30 p.m.
Plant Management was 4
informed of a potential procedural adherence problem 5
during the Unit i shutdown.
And I'd like to point out at 6
this point, in discussions between the operations manager 7
and the Plant manager, the team determined that there was 8
no substantive discussion about the actions of the reactor 9
operator earlier that afternoon.
The discussions centered 10 on a procedural anomaly.
11 CHAIRMAN SEALE:
Let me ask.
There is 27 and l
12 a half hours between the first bullet and the second 13 bullet, on that slide?
/%
)
's-)
14 MR. DAPAS:
No, that should have been on the 15 21st at 9:30 -- on the 21st.
That's incorrect i
16 CHAIRMAN SEALE:
So, that whole seance started 17 on the 21st?
18 MR. DAPAS:
Correct.
Started at seven in the 19 morning with shift turnover -- it actually started before 20 that --
21 CHAIRMAN SEALE:
Okay, and at 11 o' clock was 22 when you got into the question of whether or not it should 23 have been 11:20 or 11:40 or whatever that --
24 MR. DAPAS:
Right.
At 9 -- I think it was
/x()
25 around 9:30 -- in the morning it was identified that the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344 433 WASHINGTON, D C. 20005-3701 (202) 234-4433
'I 517 1
plant had to be in hot shutdown 20 minute earlier than f-2 originally thought.
'~]
3 CHAIRMAN SEALE:
New, this nuclear engineer --
4 or these nuclear engineers -- is that in fact, the same 5
crew or different people fulfilling the same 6
responsibilities?
7 MR. DAPAS:
No, the qualified nuclear engineer 8
who was assigned to monitor the Unit i shutdown voiced L4 s 9
concern with his supervisor, the lead nuclear engineer, 10 and then together both individuals approached the shift 11 engineer while the operating crew was still on shift, to 12 discuss their observations with the shift engineer.
13 The shift engineer did not appreciate the
,0 (s /
14 significance of what the nuclear engineers were explaining 15 to them, and he said, go out and talk to the Unit 16 supervisor and primary NSO.
And when the nuclear 17 engineers meeting -- the lead nuclear enginaer and the 18 involved, qualified nuclear engineer -- spoke with the 19 Primary NSO and unit supervisor, those two individuals 20 simply indicated that they were following their 21 procedures.
22 So then the nuclear engineers elevated it to 23 the next management level and set up a meeting with the 24 assistant Ops manager at 6 p.m.
And then the assistant (a) 25 Ops manager informed his supervisor, the Operations NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D.C. 20005-3701 (202) 234-4433
1 518 1
manager, subsequent to that and the Plant manacer who was 7-,
2 offsite received a phone call around 8:30 that evening.
~
3 CHAIRMAN SEAL 2:
But these are the same people 4
involved?
5 MR. DAPAS:
Right.
Right.
6 CHAIRMAN SEALE:
Okay, fine.
7 MR. DAPAS:
The lead nuclear engineer was not 8
in the control room at d didn' t observe actual rod 9
manipulations.
He was in his office or in other areas of 10 the plant, But the QNE of course, was there.
i 11 Before I discuss the augmented inspection 12 team's specific findings, I would like to emphasize that 13 this event did not pose a risk to the health and safety of
/-
e lx_l 14 the public.
However, the event was certainly considered 15 safety-significant from a human performance perspective.
16 Based on the team's understanding of the 17 sequence of events, the results of interviews conducted by 18 the team, and the review of existing procedural guidance, 19 the augmented inspection team determined that the more 20 significant root causes for this event included:
21 (1) A breakdown of command and control of 22 Operations Supervision; 23 (2) inadequate communications between 24 operators, Operations Supervision, Operations Management, f'N
)
25 and Nuclear Engineering Department personnel; NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344433 WASHINGTON, D C. 20005-3701 (202) 234-4433
519 1
(3) the failure of Operatiens Supervision, l
2 Operations Management, and Plant Management to provide o
3 clear direction to the operating crew regarding the 4
planned shutdown; 5
(4) the failure to pre-plan the shutdown 6
evolution; licensed operator training deficiencies; and 7
(5) the existence of a number of control room 8
distractions during shift activities.
9 MEMBER APOSTOLAKIS:
Excuse me.
10 MR. DAPAS:
Yes.
11 MEMBER APOSTOLARIS:
Isn't the term 12
" inadequate communication" kind of broad, here?
13 MR. DAPAS:
I'll give --
14 MEMBER APOSTOLAKIS:
The nuclear --
15 MR. DAPAS:
you some examples 16 MEMBER APOSTOLAKIS:
The qualified nuclear l
l 17 engineer did talk to the NSO, and the NSO just didn't pay l
18 attention, it says.
Why make the NSO responsive, he's l
I 19 just following procedure.
Is that really failure to 20 communicate?
I mean, at a certain level it is, but I 21 wonder whether there is another root cause here?
22 MR. DAPAS:
There's some other aspects here.
23 When we talked about inadequate communications we 24 identified cases where 3-way communications were not being 25 exercised properly in the control room.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D C. 20005-3*01 (202) 234 4 433
520 1
For e:tample, the primary nuclear station 2
operator announced, I believe -- what was it, the shutdown 73
(
)
3 margin alarm -- and that was not acknowledged by the Unit 4
supervisor.
There were some indications of the continual 5
control rod insertion and tnen withdrawal that were 6
announced by the primary NSO that were not acknowledged in 7
all cases by the Unit supervisor.
8 MEMBER APOSTOLAKIS:
What exactly is the 9
definition of communication?
10 MR. DAPAS:
Well, the licensee's procedure, 11 when it talko about 3-way communication, a communication 12 is voiced by the originator, repeated by the recipient, 13 and then acknowledged by the originator that the
/~N
(_ l 14 recipient's communication was in fact, correct.
15 MEMBER APOSTOLAKIS:
So communication is 16 really the transmission of information?
17 MR. DAPAS:
Right, and there's two parts to 18 that.
To me, it's the transmission and receipt.
Yes.
19 MEMBER APOSTOLAKIS:
The receipt.
20 MR. DAPAS:
The primary nuclear station 21 operator heard the ONE's concern lut didn't resolve that.
22 MEMBER APOSTOLAKIS:
So that's not --
23 MR. DAPAS:
There was inadequate communication 24 when Plant Management expected the involved operators to r-(x) 25 be removed from licensed duties -- which I'm going to talk NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D.C. 20005-3701 (202) 234-4433
l 5211 about subsequently -- and they were not.
There was 2
inadequate communicatiens-there.
3 When I talked about the informal briefing, 4
plant Management intended to convey that is acceptable to 5
shut down the Unit, fix the containment's spray pump, and 6
then we'll restart the Unit.
But that was an ineffective 7
communication between the involved individuals 8
participating in that intermal briefing, each left with a 9
different understanding of when the decision point was 10 going to L a proceed to hot shutdown.
11 I believe the operations manager thought that 12 when they reached seven percent power, if they hadn't 13 restored the containment's spray pumo by that point, they l'D Cl 14 were going to go to hot shutdown; whereas the shift 15 engineer left that meeting with no understanding that 16 there had been any decision point made, and of course 17 subsequently that's why he did not provide any direction 18 to the operating crew during the formal briefing.
19 And I believe the assistant ops manager left 20 the r.itrol room with the understanding that when they got 21 the 10 or 15 percent power, they were going to proceed 22 deliberately to hot shutdown.
So that's what I attempted 23 to convey.
24 MEMBER APOSTOLAKIS:
But I'm discussing a r))
25 difference instance here.
The qualified -- on page 9; NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLANC AVE, N W.
(202) 234 4433 WASHINGTON, O C. 20005-3701 (202) 234-4433
522 1
perhaps we can go to 9.
The qualified nuclear engineer 2
observes excessive control rod insertion and questions the (n\\
\\'j 3
primary NSO.
The primary NSO responds that he is 4
following his procedure and continues to insert control 5
rods.
6 So is this failure to communicate or is it 7
something else?
I mean, clearly -- at least from what you 8
have there -- the primary NSO did understand -- did 9
understand -- what the QNE said, right?
10 MR. DAPAS:
Well, the primary NSO understood 11 the ONE's concerns with the continual control rod 12 insertion --
13 MEMBER APOSTOLAKIS:
So there was no failure 7
!\\_-)
14 to communicate.
15 MR. DAPAS:
Correct.
16 MEMBER APOSTOLAKIS:
He just decided not to 17 follow the advice.
18 MR. DAPAS:
There was failure to communicate 19 in my view, when the qualified nuclear engineer expressed 20 his concern to the shift engineer and said, I'm 21 uncomfortable with this up and down rod motion, and he did 22 not elaborate or explain what he meant by that.
23 MEMBER APOSTOLAKIS:
I see.
24 MR. DAPAS:
The shift engineer had no concept (M{j 25 if there had been any excessive control rod manipulations.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 2344 433
523 I
I would classify that as an inadequate communication; when 2
the primary NSo didn't understand the intent of the
(_s\\
\\
)
3 procedure step and the Unit supervisor simply re-read the 4
step, I'd consider that inadequate communication on both 5
parts.
6 MEMBER APOSTOLAKIS:
And I agree with that, 7
but you wouldn't call this 8
MR. DAPAS:
No, I would not consider that an 9
example of inadequate communications -- that particular 10 point.
You're correct.
11 MEMBEh APOSTOLAKIS:
So when we look for 4
12 causes, you know, we have to be careful to distinguish 13 between communication --
34 MR. DAPAS:
I think the inadequate 15 communication where the primary NSO did not seek 16 clarification of the intent of the procedure step, was 17 critical to the event, and I would consider that a 10 function of inadequate communications.
19 MEMBER APOSTOLAKIS:
Now, what would you call 20 this?
I mean, that the guy was informed that something 21 was going on and yet he said, well I'm just tollowing 22 procedures?
23 MR. DAPAS:
This was a failure of the 24 qualified nuclear engineer to elevate his concern to (3()
25 Operations Supervision.
Just accepting the primary NSO's NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N VL (202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
524 1
response, I'm just following procedures -- particularly 2
when the ONE approached the NSO on the rod withdrawal and 3
the primary NSO says, well I'm uncomfortable with what I'm 4
doing as well -- that certainly should have been a point 5
to flag to the ship engineer hey, time out, there's a G
problem here; we need to address what we're doing.
7 MEMBER APOSTOLAKIS:
Okay, so for this 8
particular instance I agree with you that the ONE should 9
have elevated his concern.
10 MR. DAPAS:
Right.
11 MEMBER APOSTOLAKIS:
But I'm particularly 12 interested in the attitude of the NSO.
I mean what 13 looking at your table 3 with -- page 3 with the root f%
\\_-]
Y 14 causes, I'm trying to place that attitude in one of these.
15 And I'm having difficulty.
Was it, clearly there were 16 training deficiencies --
17 MR. DAPAS:
One of the other points --
18 MEMBER MILLER:
That's my next question.
19 MR. DAPAS:
And I'm going to discuss the 20 training deficiencies and the knowledge deficiency that we 21 felt the primary NSO had.
And I guess you could qualify 22 that as a root cause.
Training deficiencies were a root 23 cause, the lack of knowledge that the primary NSO 24 exhibited, I would consider another root cause in terms of 7-25 the purest sense of what is a root cause.
N-NEAL R. GROSS CoVRT REPORTERS AND TRANSCRIBERS I
1323 RHODE iSt.AND AVE., N W.
(202) 234-4433 WASHINGTON, O C. 20005-3701 (202) 234-4433
525 3
MEMBER APOSTOLAKIS:
But this particular 2
instance, where the NSO was informed that something was t
s
\\d 3
not right and yet he said that he was following 4
procedures, what kind of cause makes him do that?
I look s
5 at the six bullets on this page 3 and I can't really place 6
it anywhere.
Is it breakdown in command and control?
I 7
mean, that's again, too broad.
8 MEMBER BARTON:
George, can we finish the 9
presentation in getting root cause, and go back and forth 10 so we can have a little continuity?
11 MEMBER APOSTOLAKIS:
Fine.
12 VICE CHAIRMAN POWERS:
Could I ask just a bit 13 of background on this?
This particular operating team, 7.-
1(_
14 had they had a history of working together or was this a 15 mixed crew?
16 MR. DAPAS:
I believe this crew had been 17 together for some time.
This was not a new combination of 18 individuals on the operating crew; they had been together 19 for some time.
20 MEMBER APOSTOLAKIS:
That's amazing, 21 though.
How long has Zion been --
22 CHAIRMAN SEALE:
Forever.
23 MEMBER APOSTOLAKIS:
So this particular 24 operator who did not know how to lower power, how long had A
25 he been employed by the utility?
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON. D C. 20005 3701 (202) 234-4433 j
iu
$hk?'
?
M 526 M
1 liR, DAPAS:
Well, there's something I'd like l
2 to point out here and I was going to discuss this O
l 3
subsequently -- that one of the training deficiencies is, 4
during initial operator license training they go through 5
an evolution where they maintain reactor power at the 6
point of adding heat, but they do not routinely train on 7
this.
8 liormally, they would just continue right to 9
liode 3 so the operator would not stop and maintain power 10 at the point of adding heat; he would continue to insert 11 the full rods and allow power to decrease to the startup h
12 rate.
This was an -- I'll call it an infrequently l
l 13 performed evolution, and that was one of the issues and we that's one of the violations that's included in the 14 15 subsequent escalated enforcement action which was just, I 16 believe, announced this past Tuesday, 17 one of the violations included the failure to 18 perform an infrequently -- failure to conduct an 19 infrequently performed evolution.
And that was one of the 20 findings of the team; that there were training 21 deficiencies and that I believe there had been -- I don't 22 recall the number exactly -- how many -- seven out; of 24 23 shutdowns over the last three years -- or last year, had 24 involved stopping at the point of adding heat.
25 This particular crew had not been involved --
NEAL R. GROSS COURT REPORTERS AND TRANSCRIDERS 1323 RHODE ISLAND AVE.. N W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 2344 433 1
527 1
or, this operator had not been involved in that evolution 2
and had not received training on that evolution in, I
()
3 think it was in the order of ten years since he was 4
initially licensed.
So that was a contributing iactor --
S the lack of training to reinforce what the expectation is.
6 The first time he had really thought about how 7
to invoke that step with stopping and maintaining power at 8
the point of adding heat, was when he was directed to do l
9 that by the Unit supervisor.
10 MEMBER MILLER:
So basically their training 11 was inadequate with manipulations at very low power?
12 VICE CHAIRMAN POWERS:
Well, I think if I were 13 to look for things it seems to me I would come back to OCl 14 the very beginning where we have a very incomplete 15 planning for -- a contingency planning for this exercise.
16 MEMBER MILLER:
Well, I'm just looking at it 17 from another viewpoint.
I've operated a research reactor 18 and they're down in that level and there's obvious a total 19 lack of feel for what the reactor's going to do here.
20 MEMBER BARTON:
Mark, do you want to finish 21 this and then we'll get into the root cause?
Because I 22 think we're jumping into root causes here.
Finish your 23 present story please; don't get into root causes.
Thank 24 you.
g i
25 MR. DAPAS:
Thank you.
Operations Supervision
%/
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 034-4433 WASHINGTON, D C. 20005 3701 (202) 234-4433
528 1
did not properly exercise its oversight responsibilities 2
for ensuring that shift activities were conducted in a 3
controlled manner and became focused on containment spray 4
pump restoration activities and balance of plant 5
problems.
6 As a result, Operations Supervidion was 7
unaware of improper control rod manipulations.
Despite 8
the almost continuous presence in the control room of 9
operations and/or Plant Management during shift 10 activities, including the shutdown evolution, no direction 11 was provided to Operations Supervision to correct the 12 command and control deficiencies, communication problems, 13 lack of teamwork, and control room distractions which (3
()
14 collectively precipitated this event.
15 This inaction by management conveyed tacit 16 approval of the existing control room conditions to 17 operations Supervision.
The actions of the primary 18 nuclear station operator in continuous withdrawing control 19 rods to re-establish power at the point of adding heat, 20 reflected a significant lack of understanding of rector 21 physics and proper control rod manipulations for a 22 controlled approach to criticality.
The actions of the 23 primary nuclear station operator were also contrary to the 24 instructions in the plant startup procedure t'~x
!]
25 Regarding command and control deficiencies, NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344433 WASHINGTON, O C. 20005 3701 (202) 234-4433
529 1
the shutdown briefing was informal, poorly planned, and 2
ineffective.
Operations Supervision did not provide any l
's 3
direction to the operating crew du:ing the briefing 4
regarding the decision point for proceeding to hot 5
shutdown.
6 Despite a number of control room indications 7
and communications, Operations Supervision was unaware 8
that the primary nuclear station operator had continuous 9
inserted control rods a total of 232 steps, which placed 10 the reactor in a substantially suberitical condition, and 11 then withdrew rods 84 steps in an attempt to re-establish 12 power at the point of adding heat.
13 Operations Supervision failed to exercise
/^i U
14 their responsibility to minimize control room distractions 15 with the potential to adversely impact the ability of 16 operators to safely conduct plant evolutions.
This was 17 evident in the number of people that were in the control 18 room at the time of the event.
19 During the eight minutes between tripping the 20 main turbine and tripping the reactor, the same time 21 period during which the primary nuclear station operator 22 excessively manipulated control rods, 39 people were in 23 the control room envelope with 15 people in the immediate 24 vicinity of the areas where the primary nuclear station 25 operator and Unit supervisor were stationed.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234 4433 WASHINGTON. O C 20005-3701 (202) 2344433
530 1
Regarding communications deficiencies.
2 Operations Supervision failed to inform the operating crew
(\\~#
3 of the intent to keep the Unit I reactor critical after 4
the main turbine had been tripped.
The primary nuclear 5
station operator did not adequately communicate and seek 6
resolution of concerns he had with the actions directed by 7
a specific step in the shutdown procedure.
8 The Unit supervisor also did not clarify the 9
intent of this procedural step for the primary nuclear 10 station operator.
This was one of the major contributing 11 causes of the event.
12 The qualified nuclear engineer assigned to 1
13 monitor the shutdown evolution did not adequately f%
(/
14 communicate his concerns with observed, control rod 15 manipulations to operations Supervision.
On a number of 16 occasions the operating crew did not exercise proper 3-way 17 communications.
18 Ineffective communications between Plant 19 Management, Operations Management, and Operations 20 Supervision contributed to poor planning for the shutdown 21 evolution.
The significance of the event was not 22 communicated to licensee management in a timely manner, 23 and licensee management did not effectively communicate 24 expectations that the primary nuclear station operator or
("'s
(,)
25 Unit supervisor and shift engineer involved in the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE.. N W (202) 234-4433 WASHINGTON, O C. 20005-3701 (202) 234-4433 u.
531 1
shutdown, be removed from license duties.
2 Consequently, these three individuals were
[-'>
3 returned to shift duties on Saturday, the day after the 4
event.
The deliberate decision by Operations Management 5
to return the involved operators to licensed duties 6
reflected a lack of appreciation for the significance of 7
the actions of the primary nuclear station operator in 8
continually withdrawing control rods in an unauthorized 9
attempt to take the reactor critical.
10 What I'd like to point out here, our 1
11 understanding of the sequence of events related to this 12 specific aspect is that the Plant manager had fully 13 intended that the involved individuals be removed from p
(s l 14 licensed duties.
That expectation was not adequately 15 communicated to the ops manager.
16 The ops manager deferred the decision to the 17 assistant ops manager, and then the assistant ops manager 18 decided that it was appropriate to return the shift 19 engineer, Unit superviool, and primary NSO to licensed 20 duties.
21 The site vice president learned of this on 22 Sunday and immediately ordered that the involved 23 individuals be removed from licensed duties.
In our view, 24 that conveyed a lack of appreciation for the significance
/^s
()
25 of the actions of the primary NSO and Unit supervisor, and NEAL R. GROSS COURT REPORTERS AND1RANSCRIBERS 1323 RHODE ISLAND AVE.. N W.
(202) 234-4433 WASHINGTON. O C. 20005 3701 (202) 234-4433
532 1
there may have been more extensive knowledge deficiencies 2
that had not been identified before returning -- and
-( 'T k#
3 corrected -- before returning that individual to shift 4
duties.
5 MEMBER FONTANA:
Did I read it properly that 6
the NOE was removed?
I think I read it -- the qualified -
7
- the QNE.
8 MR. DAPAS:
The qualified nuclear engineer I 9
believe, was removed.
10 MEMBER FONTANA:
Originally, he was kind of 11 removed.
The way I read it, I think he was -- when these 12 other guys were put back to work, the QNE was not -- the 13 way I read it.
[(_/'
14 MR. DAPAS:
Right, right.
Correct, correct.
15 CHAIRMAN SEALE:
Was there any subsequent 16 action regarding the Unit supervisor and his assistant; 17 that is, the individuals who in fact, made the decision, 18 either actively or passively, to return these people to 19 duty?
20 MR. DAPAS:
My understanding is yes, and I'll 21 defer to the licensee on that.
I know there was some 22 action taken, I believe, with the Unit supervisor and 23 primary NSO, I believe those individuals are no longer in 24 the Operations Department, but please elaborate on that if fm) t 25 you would, Mr. Eenigenburg.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
l (202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
533 1
MR. EENIGENBURG Joe Eenigenburg from 2
Commonwealth Edison.
All the individuals who have been 7_s
\\
3 involved in the event no longer are directly associated 4
with nuclear power activities in a licensed capacity.
The 5
nuclear station operator no longer is in that pos. tion, 6
the Unit supervisor and shift engineer at the time have 7
both since been transferred out of the Operations 8
Department, and there have been seme changes in the senior 9
management ranks as well.
10 CHAIRMAN SEALE:
It's a cruel world.
11 MR. DAPAS:
I'd like to just elaborate on a 12 couple of communications that I didn't mention 13 specifically.
During the control rod insertion sequence, O(/
14 the low rod insertion limit alarm was received in the 15 control room, followed shortly by the low low rod 16 insertion limit alarm.
17 The primary NSO announced each alarm but he 18 did not engage in a formal, 3-way communication with the 19 Unit supervisor.
The Unit supervisor apparently did not 20 hear the primary NSO announce each alarm and therefore did 21 not verbally acknowledge alarm status.
22 This communication failure was significant in 23 that information was available to the Unit supervisor 24 which would have prompted him to recognize that the (m
(
)
25 reactor was being put in a substantially suberitical s_/
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234 4433 WASHINGTON, D C-20005-3701 (202) 234-4433
534 1
condition contrary to expectations, 2
Also, there's another aspect where the 7s
(
)
/
3 licensee had recently conducted training where it was the 4
expectation that all alarms be announced, including 5
expected alarms.
So that was part of the dynamics that 6
were at play here where the Unit supervisor was being 7
inundated with alarms, some of which had significance in l
8 terms of being unexpected, and others that were expected l
l 9
alarms based on actions that had been initiated by either 10 the primary or secondary NSO.
So that was a contributing 11 factor.
12 And as I stated on a number of occasions, the 13 operating crew did not exercise proper 3-way
(\\/
14 communications.
Ineffective communjcation between plant 15 Management, Operations Management, and Operations 16 Supervision contributed to poor planning, as I mentioned 1?
for the shutdown evolution.
18 Operations Supervision did not assure that 19 planned reactivity changes were accomplished in a 20 controlled manner and that the effects of these changes 21 were understood and appropriately monitored, the 22 augmented inspection team identified a number of precursor 23 events with root causes related to poor communications, 24 weak command and control, and poor reactivity management.
/~'s
( )
25 Due to the absence of corrective actions in NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234 4433
535 i
some cases, and ineffective corrective actions in other 2
cases, the licensee failed to correct the underlying V) l 3
problems which contributed to these events.
The licensed 4
operator requalificaton training program was deficient in 5
that it did not include training on shutdown evolutions 6
that involve establishing and maintaining a power at the 7
point of adding heat -- other than during initial operator 8
'icense training, as I mentioned.
9 This concludes my prepared remarks and I of 10 course, would welcome any questions that you might have on 11 any of the things I've discussed.
12 MEMBER BARTON:
Are you prepared to go into 13 the you had planned to go into the root cause at the h
C' 14 end of both events, or each?
15 MR. DAPAS:
What I had hoped is, in discussing 16 the sequence of events and going through the specific 17 findings, that the basis from why we identified those root 18 causes would be evident.
I can discuss some of the 19 specific ones if you have a question, but 20 MEMBER BARTON:
Bob, you had a question.
21 CHAIRMAN SEALE:
Yes.
I recognize that some 22 of the tech spec requirements are in many ways, sort of 23 arcane.
When this whole thing started off it was with an 24 instruction that you reduce power at a rate of a quarter O()
25 of a percent per minute.
That's fairly arcane I think.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 2344433 WASHINGTO*;, O C. 20005-3701 (202) 234-4433 l
a l
536 1
But I assume there is a rationale for that associated with 2
temperatures and so on.
('o) 3 Later on, you got into trouble because you had 4
a timeline you had to meet which was 20 minutes earlier 5
than you had expected.
Were those two instructions 6
inevitably -- well first of all, was there any flexibility 7
in the quarter of a percent per minute?
Could it have 8
been a half a percent per minute without getting into 9
trouble with the tech specs?
10 MR. DAPAS:
The focus of that operating crew 11 was on restoring the containment spray pump.
12 CHAIRMAN SEALE:
Yes.
/
13 MR. DAPAS:
In talking with the shift f()
14 engineer, one of the things we learned is, he made a 15 statement that at Zion there's been a history of doing 16 whatever it takes to keep the Unit online.
And there was 17 clearly the focus on containment spray pump restoration.
18 Reducing power at a quarter percent per minute 19 the licensee felt would enable them to reach hot shutdown 20 before expiration of the 4-hour shutdown action statement.
21 When they recognized that they had 20 minutes less than 22 originally assumed, they increased the percentile 23 reduction but they -- as I indicated -- right up until six 24 minutes before the 4-hour shutdown action statement was (3
i
)
25 going to expire, that shift engineer thought that he was sa NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344433 WASHINGTON, D C. 20005 3701 (202) 234-4433
537 1
going to get the containment spray pump back.
2 He had been having discussions with, I think,
'~)
3 the systems engineer and other individuals involved in 4
restoration activities.
It was his understanding that 5
they had completed the post-maintenance testing and were 6
going through the restoration lineup for that system.
And 7
there was no, c. t the beginning of the shift, clear plan 8
for shutting down the unit, and that was essentially the 9
problem.
10 CHAIRMAN SEALE:
So in summary then, the 11 quarter or a half a percent per minute was an option that 12 was at the discretion of the supervision?
It was -- there 13 was p
()
14 MR. DAPAS:
I believe so.
I'd have to check -
15 16 CHAIRMAN SEALE:
There was no boundary within 17 the tech specs?
18 MR. DAPAS.
Right.
No, the tech specs --
19 CHAIRMAN SEALE:
On the other hand, the 4-hour 20 limit is a wall?
21 MR. DAPAS:
Right.
And the reason we give a 22 licensee four hours is because we expect the licensee to 23 conduct a controlled shutdown, and they should, if it 24 takes the licensee two hours to do that -- the intent of
(
)
25 the tech spec is not that you operate the plant up and w/
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234-4433 WASHINGTON, D.C. 20005 3701 (202) 2344433
538 1
then five minutes before --
2 CHAIRMAN SEALE:
Sure.
3 MR. DAPAS:
-- you trip the reactor and you've 4
met the intent of the tech specs.
That is not what we 5
give and the tech specs prescribe a shutdown action 6
scene 7
CHAIRMAN SEALE:
Yes, well -- orderly and 8
deliberate is there.
9 MR. DAPAS:
Correct.
And that's our point.
10 Do you wait until you've actually entered a shutdown 11 action statement before you have any discussion on the 12 shutdown plans?
I believe Commonwealth Edison has issued 13 directives discussing any entry into an LCO of a, I think f%
14 it's 72 -- or, a 6-hour duration -- they begin immediate 15 action to shut down the Unit.
16 That was one of the corrective actions that 17 they implemented.
Depending on the length of time of the 18 LCO, they will actually initiate action to shut down the 19 Unit before they get into the shutdown action statement 20 requirements.
21 CHAIRMAN SEALE:
Okay.
22 MEMBER FONTANA:
There's two -- a couple of 23
- things, one thing, it seemed kind of strange the ONE was 24 the only one who seemed to underctand the problem and he qlv) 25 was removed from service and the other ones weren't.
It i
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISt.AND AVE, N W.
(202) 234-4433 WASHINGTON, D C. 20005 3701 (202) 234 4433
539 1
seema kind of st nnge, p
And the other question io, was there hostility 2
V 3
in this particular group that all the communications in 4
the world wouldn't have helped?
5 MR. DAPAS:
Part of the problem --
6 MEMBER APOSTOLAKIS:
That's my question.
'7 MEMBER BARTON:
You're going to get cultural 8
lasue at Zion that 9
MEMBER FONTANA:
Yes.
10 MEMBER BARTON:
-- kind of question, I 11 believe.
12 MEMBER APOSTOLAKIS:
Didn't you junt say that I
13 somebody told you that the policy was to keep the Unit f')
'd 14 on1ine?
15 MR. DAPAS:
Well, in our interview with the
/
16 shift engineer and we probed, you know, his thought l'1 process and why did he direct the Unit supervisor to try 18 and keep it " critical", or try and make the reactor 19 critical, he said -- these were his words to us -- he 20 oaid, at Zion we have a history of doing whatever it takes 21 to keep the Unit online.
22 And it was this thought process of being able 23 to return the Unit quickly to power, they were going to 24 get the containment opray pump back -- rather than what n()
25 the site vice president had attempted to articulate:
go NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W (202) 234 4433 WASHINGTON. D C. 20005 3701 (202) 234-4433
540 1
to shutdown, fix the pump, and then we'll restart.
1 2'
But see, in the shift engineer's mind there 73
/
\\
3 was a comnonent that was inoperable and when you go to 4
Mode 2 you canact start up if you're in an LCO condition 9jbecauseyouhav'. inoperable equipment.
You must restore S
6 the equipment.
Fa we recognized that he could not 7
immediste)y eturn the Unit to power.
8 And that was in his thought process that, I 9
don't want to go to Mode 2 if I don't have to, because 10 once I do that and I've made a mode change I cannot 11 restart and chtnge the operating conditions to Mode 1 12 because I have this inoperable piece of equipment.
That's 13 what he explained to us, l
(3 i
1
'O 14 And of course, the Unit supervisor -- what the 15 shift engineer directed the Unit supervisor to do -- and 16 ht didn't communicate thia -- but what he was thinking is 17 not an allowed operating condition.
And that's why the 18 Unit supervisor interpreted that to mean, oh, establich 19 power at the point of adding heat.
Because you can't keep 20 the reactoi in Mode 1 as the Unit supe" -- I mean, as the 21 shift engineer had originally intended.
22 I hope that clarifies it for you.
23 MEMBER APOSTOLAKIS:
Again, on page 14 you say 24 that a number of precursor events have occurred indicating A
{)
25 similar problems but corrective actions were inadequate.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D C. 20005 3701 (202) 234 4433 g
541 1
And this is something that I think, comes up over and over 2
again in most of the is there any reason why you 7
i V
3 didn't put it on the list of root causes on page 3, or you 4
don't consider that a root cause?
5 MR. DAPAS:
It is 5
MEMBER APOSTOLAKIS:
That's feedback is it, 7
there?
I mean, this is what organizational theorists call 8
organizational learning.
How does the organization learn 9
from past experience?
l 10 CHAIRMAN SEALE:
Good and bad.
11 MR. DAPAS:
I would agree with you.
If you 12 look at the root causes and you look at the contributing i
13 causes as I discussed in the last two slides, those are qO 14 all factors that enter -- came into play in the event's 15 occurrence, i
16 Whether you call this a root cause or 17 contributing cause, I'm not sure exactly what bin to put 18 it in, per se, but the failure to take action for 19 precursors is a contributing cause, I would say, to these 20 events.
I don't know that you could -- you could say 21 it's, yes it's a root cause because you didn't reinforce 22 training objectives as a result of lessons learned from 23 previous events.
24 MEMBER APOSTOLARIS:
Yes.
(
25 MR. DAPAS:
But the important point I'd like NEAL R. GROSS COURT REPORTERS AND TRANSCRIDERS 1323 RHODE ISLAND AVE, N W.
(202) 234-4433 WASHINGTON, D C. 20005 3701 (202) 234 4433
542 1
to get across is, it was certainly a factor that impacted 2
the occurrence of this event.
And it is one of the basis
\\_ q i
'~')
3 for the enforcement action that we took because there were 4
prior opportunities for the licensee to have addressed 5
command and control problems, reactivity management, 6
concerns and communications.
7 And the licensee had initiated some actions in 8
this area but they weren't fully effective, as 9
demonstrated by the February 21st event.
10 MEMBER APOSTOLAKIS:
So what did you ack them j
11 to do?
I mean, you said you took enforcement actions.
12 MR. DAPAS:
Well, we just issued a $330,000 13 civil penalty this past Tuesday and the licensee will need
( ~)
(- /
14 to respond to that.
There's a number of actions that the is licensee took immediately after this event that we 16 documented in the augmented inspection team report.
17 I think this event has received a lot of 18 industry interest.
I think INPO initiated an SOER, or SER 19 if I remember correctly.
And the licensee has taken a 20 number of actions.
We have an 0350 startup plan in place 21 at Zion.
The guidelines from 0350 we're using to support 22 our assessment of the licensee's corrective actions in a 23 number of areas, and part of that includes assessing 24 corrective actions in response to this event.
,/ 3
( )
25 There's also a confirmatory action letter that NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234-4433 WASHINGTON, D C 20005 3701 (202) 234-4433
543 1
we issued that discusses specific elements that the 2
licensee must respond to, associated with this event.
7 3
MEMBER APOSTOLAYsIS:
I guess I -- what's a 4
little puzzling to me is how you come up with the root 5
causes, because there are certain thingc that you describe 6
during the incident is happening during the incident g
7 deficiencies -- yet they are not on the list of root 8
causes.
Unless this is an incomplete list.
9 MR. DAPAS:
Well --
10 MEMBER APOSTOLAKIS:
Let me give you a couple 11 of examples and maybe you can tell me.
One is, you very 12 clearly stated during the description of the incident that 13 the NSO did not really understand reactor physics, right?
I
't V
14 I mean, I'm amazed that they didn't know how to reduce 15 power, and that you don't wait until --
i 16 MR. DAPAS:
I believe the --
17 MEMBER-APOSTOLAKIS:
-- it goes all the way 18 down.
19 MEMBER BARTON:
But George, I think -- this is 20 not unusual design.
I think the industry has found this 21 out from different events, INPO has increased focus in 22 this area.
And I think what's happened over the years is, 23 your basis reactor theory, physics, reactivity -- all 24 those issues are taught and learned as part of the initial Q[
\\
25 licensing process.
HEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, O C. 2000S 3701 (202) 234-4433
miedd u
544 1
How, what's happened over the years is, you've gone into fundamental tests by the NRC to test licensed 3
candidate's knowledge in these areas.
And then after that 4
it's more plant experience, simulator training, 5
transients, emergency preparedness.
And you do not 6
refocus on the basic elements of reactor theory and 7
physics.
8 I think this is an industry-wide issue that's 9
been identified recer.tly by the industry and also INPO, l
10 and I think this is an indication.
this is an area that l
l 11 licensed operators don't get to practice a lot.
Most of 12 your simulator scenarios deal with transients and crash 13 and burns, because you want to see -- everybody's q
V 14 interested in, can the plant handle a transient, how do 15 they react in emergency, normal shutdowns and startups.
16 You only have so much time in simulators, all 17 right, and you're getting ready for a license exam, you're la getting trained for handling transients emergencies, 19 you're getting ready for INPO evaluations.
Nobody really 20 testing you on, can you take the reactor critical and 21 subcritical.
And that gets lost.
22 MEMBER APOSTOLAKIS:
Yes, but that explains 23 why it happens, but my point is that I rarely see a 24 discussion on technical knowledge.
I mean, this is
,/m
(
)
25 probably the first time that somebody said there's an NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE. N W.
(202) 234 4433 WASHINGTON, O C. 20005-3701 (202) 234 447 l
545 1
industry-wide problem -- at least in my presence.
7_
Usually people talk about training 2
i ]
3 deficiencies when they realize that the operators or 4
somebody didn't really know semething well.
You say, well 5
it was probably training.
I get from what you just told 6
me that training doesn't really cover a lot of things.
I 7
mean, the basic knowledge of reactor physics is something 8
that you learn at the beginning, but then, you know.
(
9 Isn't it true that there is a general 10 reluctance on the part of the industry and the NRC to 11 really talk about what kind of knowledge various people 12 should have?
13 MEMBER BARTON:
I'm not sure that there is at
,/~T (m/
14 all.
And as a result of events that are associated with 15 this low power shutdown, there have been lots of events in 16 the industry in this area.
The training people have gone 17 back and reinstituted the reactivity and physics in 18 requalification training.
19 So the industry is putting this back in the 20 training programs to try to compensate for these issues.
21 CHAIRMAN SEALE:
Yes, the identification of 22 required knowledge and -- well, of knowledge for operators 23 is this first step in establishing what the components of 24 what the training program should be.
(a) 25 MEMBER BARTON:
That's right.
HEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS I
1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D C-20005-3701 (202) 234-4433 l
546 1
MEMBER APOSTOLAKIS:
Yes, but it doesn't cover 2
everything.
I,)
3 CHAIRMAN SEALE:
What?
4 MEMBER APOSTOLAKIS:
It does not cover 5
everything -- the training program, right now.
6 MEMBER BARTON:
Yes, it does --
7 MEMBER APOSTOLAKIS:
The basic knowledge 8
MEMBER BARTON:
Yes, it does.
It covers the 9
basic knowledge.
Maybe you misunderstood what I said.
It 10 is covered in bacic knowledge and it is examined through 11 the fundamentals exam which NRC tests all licensed 12 candidates for now.
13 What I'm telling you is that requalification Ab 14 training, or training that is ongoing after people are 15 licensed, doesn't necessarily go back and pick up the i
16 basics.
Now, in this area of reactor physics and theory, 17 because of some events in the industry, it has gone back 18 and refocused on those, you know, basic fundamentals that 19 people are taught the first time through the program.
20 MEMBER APOSTOLAKIS:
I guess it's also a 21 matter of perspective.
What really worries me about this 22 is that the QNE did try to point out that there was a 23 problem with excessive control rod insertion and the 24 primary NSO simply dismissed it.
I mean, why --
(%
ij 25 MEMBER KRESS:
This seems -- is this plain a NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 234 4433
547 1
lack of intellectual curiosity?
2 MEMBER APOSTOLAKIS:
Yes, the questioning, how 3
did you --
4 ME11BER KRESS:
-- reflecting the attitude 5
about 6
MEMBER APOSTOLAKIS:
what he's talking 7
about, lack of appreciation of the event I don't know.
l 8
I don't know what that tells us, okay, but I find it a 9
little bit now, is that buried under breakdown in 10 command and control, or is more 11 MR. DAPAS:
What we tried to capture there, 12 the primary nuclear station operator intended to continue 13 to withdraw control rods.
The only reason he stopped is
,9
.U 't 14 because he was directed to trip the reactor.
And in the 15 team's view, that was a fundamental lack of appreciation 16 for reactor physics in terms of a controlled manipulation 17 of the control rods when you approach criticality.
18 Inserting control rods for 3 minutes and 48 19 seconds and then turning around and withdrawing control 20 rods with the intent of taking the reactor critical, is 21 not the way you conduct a startup.
You're not trained on 22 that, it's fundamental to reactivity management and 23 control of a reactor, and in our view, that reflected a 24 lack of appreciation for reactor physics.
)
25 You would have continued to withdraw control NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234 4433 WASHINGTON D C. 20005-3701 (202) 234-4433 l
548 1
roda, you establish a positive startup rate, power 2
overshoots, and I believe the licensee's done an I
k2 3
evaluation -- I don't know that you would have gotten 4
activation of a protective device, but clearly the intent 5
-- you know, we talk about doing -- you withdraw control 6
rods and you observe startup rate reactive power increase, 7
but you don't continuously withdraw control rods in an 8
attempt to increase power until power indicates the point l
9 of added heat, and then power is going to continue to l
10 increase above that.
11 That's not the expectation, and that's what we 12 were trying to focus on with this lack of understanding of l
13 reactor physics, specific to control rod manipulations for O
(_,/
14 a controlled approach to criticality.
We're not indicting 15 his knowledge of reactor physics across the board, but in i
16 this specific aspect we felt it was deficient.
17 MEMBER BA.',rON:
So sensitivity to reactivity 18 insertion was not there -- it was not there.
19 MEMBER APCSTOLAKIS:
I guess the only -- I 20 agree with what you're saying.
The reason why I'm asking 21 tne questions is because I look at page 3, the root 22 causes, and I don't see the two things that struck me as 23 being very important, and one of them we see all the time.
24 One is learning from experience this
,a
(
)
25 feedback thing from the precursors -- and second is this NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234-4433 WASHINGTON, O C 20005-3701 (202) 234 4433
549 1
questioning attitude and all the reactor physics 2
knowledge.
Which brings me to the question really, wha t-
[
)
V 3
is the purpose of slide 3?
You identify the root causes -
4
- these are some of the root causes?
5 MR. DAPAS:
I said the more significant root 6
causes for this, an clearly -- and that's the way we 7
characterize it in the augmented inspection team.
There 8
are another, like ten conclusions and findings, some of 9
which you may be able to attribute as a root cause.
10 As I went through some of these -- and I don't 11 disagree that they may be better binned as a root cause 12 versus a contributing cause, but hopefully, collectively, 13 I conveyed what we felt were the reasons for why the event
>q i
C/
14 occurred.
15 And perhaps there are other significant root 16 causes that should be captured in slide 3, like the issue 17 you just mentioned:
the failure to provide corrective l
18 actions for precursor events.
But that certainly was a 19 central theme in the augmented inspection team report, and 20 the basis for subsequent enforcement action.
21 MEMBER APOSTOLAKIS:
Okay, okay.
22 MEMBER BARTON:
One of the committee members 23 had a question on human factors.
We are going to get a 24 presentation on human factors from the NRC this morning; f3 J
25 from the staff.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE.. N.W.
(202) 234-44 %
WASHINGTON. D.C. 20005-3701 (202) 234-4433
l 550 1
1 MEMBER APOSTOLAKIS:
Oh, this is not it?
2 MEMBER BARTON:
No, this is really going 7-i,
)
3 through the events in the AIT.
We're going to go through 4
the sequence of events at the Clinton Station, and we're 5
going to get a presentation on human factors' aspects of 6
both these events.
7 CHAIRMAN SEALE:
Maybe we'd better move on.
8 MEMBER BARTON:
Yes, we --
9 MEMBER KRESS:
As to risk of -- over here --
10 as to risk of revealing my ignorance, could you tell me 11 exactly what you mean by the term, "the point of adding 12 heat"?
13 MR. DAPAS:
The point of adding heat is where Y/
14 you get the temperature temperature coefficient of i
15 reactivity comes into play, where when you m,alpulate 16 control rods and you see an impact on natural power, 17 that's the point --
18 MEMBER KRESS:
Comes into play at some 19 percentage level?
20 MR. DAPAS:
Right.
21 MEMBER KRESS:
Because it's always -- in fact, 22 it goes through ups and downs.
23 MEMBER MILLER:
At what percent power would 24 that be in this PWR?
,.(,)
25 MR. DAPAS:
In this particular plant it was i
HEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
551 1
2,5 X 10 2 percent, or.025.
2 MEMBER KRESS:
Okay, and that's established by f~
3 previous tests on the reactors?
4 MR. DAPAS:
Right.
5 MEMBER MILLER:
So they were just 6
MR. DAPAS:
I'd defer to someone who might 7
have more knowledge. My recollection from my training when 8
I was in the Navy was that that's where you see reactivity 9
temperature feedback -- when you do a temperature change 10 and you see an actual impact on indicated power.
11 For example, do you increase steam demand and 12 it causes temperature to decrease?
You know, with a 13 negative temperature coefficient you would actually see a 73 14 reactivity increase resulting in a change -- or increase i
15 in power.
And at that point is the point of added heat, i
16 You're withdrawing control rods through the 17 intermediate range and then when you get to the point of 18 added heat, that's where the temperature coefficient 19 reactivity comes into play in terms of seeing a power 20 change as a result of temperature decrease.
21 MEMBER BARTON:
Mark --
22 MR. DAPAS:
Correct me if I'm --
23 MEMBER BARTON:
Okay.
But if you were 24 finished with your prepared presentation?
(,/
25 MR. DAPAS:
Sure.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE.. N.W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
552 1
MEMBER BARTON:
At this point I think we need 2
p-to move on to the Clinton event so we can get into that, i)
3 and then the human factors, and we can also come back and 4
ask some question of Mark after those presentations.
5 CHAIRMAN SEALE:
I'm going to be very brutal 6
about the time on -- because we've got a busy day.
7 MEMBER BARTON:
Thank you.
8 MR. WRIGHT:
Good morning.
My name is Jeff 9
Wright.
I am the Region III branch chief responsible for 10 the clinton facility and have been in that position since 11 November of
'96.
12 I'm here to discuss the event at the Clinton
)
13 power station of one year ago today, where the "B"
reactor
, f3 l I j
(_/
14 recirculation pump seal failed, when supervisors -- that l
15 is, the shift supervisor -- and a station manager made 16 non-conservative decisions to address non-identified 17 drywell leakage.
18 Beyond the specific issues identified during 19 our inspection activities, this event, as was the Zion 20 one, was particularly significant because these days, 21 while we normally see operators you could say, coming to 22 the rescue and saving the plant because of equipment 23 failures or the like, in this particular situation we saw 24 operators actually causing the problem -- or in this O)
(,
25 particular, more exactly, aggravating the problem here.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
553 1
Before we get into the specific event, a r~s 2
little bit of background I think, will be helpful, The l
\\
3 "B"
recirculation pump has had a history of seal 4
degradation over the years.
The seal package for that 5
pump has been replaced I think, approximatoly seven times.
6 On the "B" pump it's interesting to note that the seal on 7
the "A" pump has only had to have been replaced once.
8 The "B"
seal package started to show, on this 9
occasion, started to show a degradation following startup 10 from an April '96 reactor scram.
In June of '96 ar 11 opportunity existed to replace the seal when the Unit was 12 manually scrammed.
The seal was not replaced at that 13 time.
/~'N
\\
1 x/
14 The seal continued to degrade over the next 15 several months.
In August there was a noted increase in 16 drywell unidentified leakage.
That increase was about
.6 17 gallons per minute.
Illinois Power, the licensee in this 18 case, believed that the leakage was coming from the 19 degrading seal package.
20 Following that increase, an administrative 21 limit of four gallons per minute was placed on drywell --
22 unidentified drywell leakage.
Engineering, through 23 calculations, estimated that the time that that value 24 would be exceeded would oe around September 6th.
It n()
25 should be noted that a refueling outage was scheduled -- I NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
554 1
should say September 6th -- the refueling outage was 2
scheduled for October '96.
-~
3 The crew that was on on September 5th was not 4
a normal crew.
While it was in size, it was far from 5
normal in its complement.
The shift supervisor had not 6
worked with this particular crew before.
The line 7
assistant shift supervisor -- that's the control room SRO 8
-- had not worked with this crew before and had recently 9
tendered his resignation from the company.
10 The two ROs who were on shift did normally 11 work together, and the STA that was on shift had worked 12 with neither one of the SROs in the past.
In addition to 13 those five individuals, there was an extra reactor m
\\m-14 operator on shift to provide double verification during 15 control rod movements, and the recirculation system 16 engineer -- system engineer, was in the control room for 17 the evolution.
18 On September 5th a decision was made to 19 proceed to single loop operation.
That was to allow 20 continued operation of the Unit with only one of the two 21 recirculation pumps in service because of increasing, 22 unidentified drywell leakage.
23 If that leakage could be eliminated or reduced 24 the plant would be able to continue to operate until the
/~%
)
25 planned refueling outage.
A shift briefing had been held v
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D.C. 20005-3701 (202) 234 4 433
555 1
to discuss the evolution.
It should be noted though, that 2
at this point that no special training had been provided
, ~x i
)
' '/
i 3
for the crew on single loop operation, to say nothing 4
about attempting to go to single loop operation with a 5
degrading, or potentially degrading seal.
6 Those activities, single loop, would have been 7
addressed during routine training only to the extent that 8
it was a precursor as mentioned before, for some of the 9
more exotic scenarios during the requalification program.
10 But a full sequence of training in this area had not been 11 specially -- had not been given specially to this group, 12 nor was it part of the routine training.
13 MEMBER BARTON:
Was it handled as an
,9
?
\\_/
14 infrequently performed evolution?
You know, with all the 15 formality that goes with that?
16 MR. WRIGHT:
No, it was a routine briefing.
17 MEMBER BARTON:
Okay, thank you.
18 MR. WRIGHT:
At this point, unidentified 19 leakage in the drywell was around 3.9 gallons a minute.
20 It should be noted that the technical specification limit 21 on unidentified leakage is five gallons a minute.
22 In preparation for removing one of the loops 23 from service, recirc loops, control rods were inserted 24 taking reactor power from 100 percent down to about 81 m
(
)
25 percent.
Following the reduction in power, the "B"
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE. N W.
(202) 234 4433 WASHINGTON, D C. 20005 3701 (202) 234 4433
f56 1
recirculation flow control valve, the pump discharge valve 2
were closed and the pump was secured.
That left only the 7-s t
3 suction valve open.
Power at this point was about 58 4
percent.
5 The reactor was essentially in a stable 6
condition with one recirculation loop in service.
7 operators calculated at this point that it would take l
8 about six hours for the idle loop to cool down to less 9
than 250 degrees, which is a procedural limit for 10 continuing to secure the idle loop.
11 Note that up to this point, the evolution had 12 been well executed and controlled.
They were in no
/
13 shutdown limiting conditions for operations, and the crew f(_)
14 could have sat there and monitored leakage and allowed the 15 loop simply to cool down before proceeding.
16 The shift supervisor though, in consultation 17 with the acting Operations Department manager, decided to 18 move ahead even though the procedure had a limit of the 19 250 degrees before proceeding.
20 Their first action was to close a staging -- a 21 seal staging valve on the recirculation pump seal.
That 22 evolution was taken, like I said before, even though 23 before that stuff was to have occurred, temperature was to 24 have been allowed to decrease to less than 250 degrees.
/^)\\
\\
25 Within about 25 minutes of performing that v
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344433 WASHINGTON. D.C. 20005-3701 (202) 234-4433
557 1
action, leakage jumped from around 3.9 or 4 gallons-a-2 minute to about 5-and-a-half gallons-per-minute.
It
-s
/ T
'\\~')
3 should be noted that the original drywell sump real time 4
monitoring, leakage monitoring system, was not available 5
due to biological following of the system.
An installed 6
backup system was working, although there is a time delay 7
in obtaining leakage because it's a pump runtime kind of a 8
system.
9 What is interesting to note at this point is 10 that the staging flow valve that they had shut off, that 11 they had closed, was allowing about one gallon a minute, 12 approximately, to go to an identified leakage source.
13 When that valve was closed, drywell leakage increased --
p
's _
14 unidentified, increased somewheres between one and one-15 and-a-half gallons-a-minute.
There is some thought that 16 it simply diverted from an identified source to an 17 unidentified source now.
18 Once the identified leakage exceeded five 19 gallons-a-minute, the facility declared an unusual event 20 and entered a 4-hour limiting condition for operation for 21 a Unit shutdown.
Interesting to note at this point that 22 there were, because of the increased in leakage rates, rad 23 protection was to have been identified to help identify if 24 there were other sources of leakage.
That notification p) t 25 never occurred.
s NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON D C. 20005-3701 (202) 2344433
\\
558 1
Because, based on the EP declaration, the crew 2
closed the recirculation pump suction valve, there was no 7-s
!' ')
3 noticeable change in drywell leakage.
This was basically 4
an inappropriate application of an emergency response 5
declaration to allow deviating from a procedure.
That is, 6
they closed the suction valve out of sequence.
7 Around 10 o' clock in the evening, again to 8
hasten the cool down, the shift supervisor, after 9
discussing his actions with the then, acting department 10 Operations Department manager, the system engineer, and 11 the assiutant -- line assistant shift supervisor --
l 12 directed that the seal injection valve from the control 13 rod drive hydraulic system, be closed.
,m 14 This completed all of the actions necessary at 15 this point, to completely isolate that loop.
Again, that 16 action was not to have been taken until the loop had 17 cooled to less than 250 degrees, or the seal was 18 determined to have already been failed.
That 19 determination though, was defined as that the pressure in 20 the seal package was approximately equal to drywell 21 pressure, saying it was just open to the atmosphere.
22 Neither was the case at this time.
23 About 20 minutes after completing that 24 evolution, the seal rapidly depressurized from around 950 7( )
25 pounds down to about 280 pounds, drywell pressure started NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON. D C. 20005-3701 (202) 234 4433
559 1
to trend up, and drywell leakage rapidly increased and 2
exceeded 7.99 gallons-per-minute.
Basically at this J
-f\\
/
\\
3 point, the depressurized volume and the research loop 4
between the suction and the discharge value.
5 I mentioned the 7.99 figure as being exceeded.
6 It's interesting that a modification -- the backup 7
modification to drywell leakage monitoring system that had 8
been installed to back up the originally designed leakage 9
monitoring system, when originally designed had a cap on 10 its indication placed at 7.99 gallons-per-minute.
11 The crew was not particularly aware of this l
12 limitation, and it diverted their attention for some time 13 in trying to figure out whether that value was correct or i
(. l 14 not.
Again, not recognizing that once the value exceeded 15 that, you know, it just blocked it at that point.
i 16 It was not until a relief STA came to the 17 control room during shift turnover that this design 18 feature was more clearly understood, and drywell leakages 19 were calculated manually.
Calculations indicated that the 20 leakage had peaked -- this is original calculations --
21 around 38 gallons-per-minute, and that occurred somewheres 22 around 10:37 in the evening.
23 Subsequent calculations actually put the 24 leakage closer to 20 to 30 gallons a minute.
It's r( )j 25 interesting that, other than observing the actual leakage NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
560 1
rate at this point, no other actions that would have 73 significantly impacted the observed leakage, were taken 2
(\\")
3 for the rest of that shift.
4 There was a shift change at this point, and we 5
move on to September 6th, where around one o' clock in the 6
morning, identified leakage had stabilized at about ten 7
gallons-a-minute.
This essentially amounted to the 8
leakage past the recirculation pump isolation valves.
9 At about five-minutes-to-one in the morning, 10 the 4-hour limiting condition for operation expired and 11 the Unit entered a 12-hour to hot shutdown condition.
It 12 was not until 2 a.m.
that a briefing was conducted with 13 the shift on actually shutting down the Unit, and it was O
\\>
14 another half-an-hour until actual power reduction started.
15 Between about 2 a.m.
in the morning and 6 16 a.m., power was reduced from 58 percent to 23 percent.
17 That averages to about nine percent per hour.
Again, with 18 this size of the power change, chemistry was to have been 19 notified so that they could take water samples.
That 20 notification was not made.
21 The turbine was finally removed from the grid 22 around 11 o' clock in the morning, and the reactor was 23 manually scrammed a little bit after noon.
Some of the 24 complicating issues that occurred during that shutdown --
f~~h
(,)
25 they ended up entering an emergency operating procedures NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 2344433 WASHINGTON. D C. 20005-3701 (202) 234-4433 f
561 1
when the level in the suppression pool went high.
2 There were two reasons for that.
One, they I
\\
l 3
had been flushing some lines in preparation for having --
4 for replacing the "B"
recirc pump seal.
That added a 5
considerable amount.
They also had leaking safety relief 6
values that came from the April scram.
When maintaining 7
the Unit in a hot condition the safety relief valves had 8
been cycled about 85 times.
9 An operator made an electrical switching 10 error, in that early on the morning of the 6th they had 11 lost some non-vital busses at that -- non-vital equipment 12 at that time -- they had to stop and recover from.
And at 13 one point there was -- a fire had been reported, six O
j
(,,/
14 operators responded to the location but there was no fire.
l 15 MEMBER BARTON:
Was that the fire brigade or 16 just six operators?
17 MR. WRIGHT:
It would have been the dedicated 18 fire brigade.
19 MEMBER BARTON:
Okay.
20 MR. WRIGHT:
Based on the conclusions of a 21 special inspection that was conducted into the activities 22 on the evening of the 5th and the morning of the 6th, and 23 an operational safety team inspection, as well as 24 interviews conducted by the Office of Investigations, a
,x (v) 25 number of causes were identified on this particular event.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D.C. 20005-3701 (202) 234-4433 l
562 1
One of those being that the management at this g\\
utility had not properly balanced economic issues with 2
r s
3 safe operation during the normal day-to-day activities 4
over the course of the last year or so.
Site supervision 5
and management inappropriately emphasized attaining a 6
single loop configuration to allow continued plant 7
operations.
8 Individuals focused on operating the facility 9
rather than more conservative decision to shut the unit 10 down.
With additional inspections we identified that 11 basically, the Clinton Power Station had established an 12 environment that condoned procedural compliance through l
l l
13 accomplishment of the user's interpretation of the
,q
(,)
14 procedure's intent without appropriate regard for the 15 actual, procedural steps.
\\
16 There was a pervasive problem with procedural 17 adherence at the facility.
Corrective actions had not 18 been effective for the previous pump failures.
And there 19 was significant training deficiencies as we had noted 20 before, both in actual performance of this activity, in 21 the operator's understanding of the leakage detection 22 systems, and its limitations.
23 The licensee implemented a start-up readiness 24 action program to address the procedural adherence (3) 25 problems, the conservative decision-making problems,
.r as NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W.
(202) 234-4433 WASHINGTON, D C. 20005 3701 (202) 2344433
563 1
well as a number of equipment issues.
At a later time 2
they developed a strategic plan to look more broadly at
,_s
\\
3 the issues and develop parametrics to assess the
~'
4 effectiveness of their corrective actions.
5 To address this issue the NRC, as we've 6
mentioned before, set up a special team, a special 7
inspection led by the resident inspector at the time.
8 That was followed up by a operational safety team 9
inspection.
10 Out of those two inspections, enforcement 11 action for this particular event resulted in one Severity 12 Level II violation being cited, and two Severity IIIs, for i
13 a total of $350,000 civil penalty.
But if you look at the
,-~
)
\\s /
14 actual package you will see other items in there that 15 brought the total up to about $450,000.
16 To respond, going back to our response, we 17 augmented the inspector -- resident inspecto; staff at the 18 site, bringing in two additional inspectors.
We placed 19 the Unit in a single Unit Branch -- a dedicated branch 20 chief.
We also formed a special panel made up of regional 21 and NRR individuals to monitor the licensee's corrective 22 actions and to ensure that the NRC was able to bring the 23 appropriate technical expertise to issues that needed to 24 be resolved.
, -~s
)
25 The panel, by the way, is still in existence.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON. D C. 20005-3701 (202) 234 4433 1
~
l
564 1
That concludes my prepared remarks, I'd be happy to 2
answer any questions that you have.
(')
3 MEMBER UHRIG:
Was there any explanation given 4
as to why they proceeded when all they had to do was wait?
5 MR. WRIGHT:
The explanation provided by the 6
shift supervisor was, he believed that he was in an 7
abnormal procedure requiring him to identify and stop the 8
I mean, that's what he believed.
9 Interesting though, that the unidentified leakage had been 10 occurring for some time before that, and that procedure l
11 had not been entered.
12 MEMBER UHRIG:
Was there in fact, such a 13 procedure requirement?
(,/
14 MR. WRIGHT:
There was a procedure that, you 15 should take actions to identify and isolate leakage to the 16 extent practical.
17 MEMBER KRESS:
It would -- you said it would 18 have been more conservative for them to go ahead and shut 19 down; to retire this pump.
I believe that's true in this 20 case, but is that always the case that it's better, more 21 conservative to shut down rather than to operate at some 22 power level, to do maintenance and replace things?
23 MR. WRIGHT:
It wouldn't always.
I mean, 24 single loop operation is recognized and is an allowable
(
)
25 condition --
'n.J NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4 433 WASHINGTON, D.C. 20005-3701 (202) 234-4433
{
l l
565 1
MEMBER KRESS:
It's an allowable condition.
2 MR. WRIGHT:
and so if they had looked and t
/
v 3
had attempted this maybe earlier, where the leakage wasn't 4
as bad, where you wouldn't have these conditions -
or had 5
followed the precedure -- they may well have successfully 6
ended up in single loop operation without a problem.
7 CHAIRMAN SEALE:
That is a discretionary 8
alternative?
9 MR. WRIGHT:
That is an alternative, yes.
10 CHAIRMAN SEALE:
Maybe we ought to go ahead 11 and do --
12 MEMBER BARTON:
I've got one question.
It's 13 something that's bothering me.
How did they end up with U
14 that mix on a shift crew that never -- I assume what you 15 said is that it was not the normal crew complement; in 16 fact, the only -- well, what I think I thought I heard was 17 only the two control room operators were members of that 18 crew -- how did it end up with that unusual mix without 19 having trained that particular crew composition?
20 MR. WRIGHT:
Mike, would you like to address 21 that?
22 MR. LYON:
Certainly.
My name is Mike Lyon; 23 I'm the assistant plant manager in operations.
The 24 circumstances that led to that crew composition being, as g) i 25 Mr. Wright has indicated, was due to a transition from a NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., f W.
(202) 234-4433 WASHINGTON, D.C. 20005-3701 (202) 234 4433 J
566 1
5-shift rotation -- or, a 6-shift rotation to a 5-shift 2
rotation in preparations for an upcoming outage.
t 3
And we had failed to take the opportunity to 4
provide training to those individuals to ensure that the 5
crew complement would be used to working with one another.
6 And we have since taken actions to ensure that core 7
composition of crews is protected for future operations at 8
the plant.
9 MEMBER BARTON:
Thank you.
Any other 10 questions at this time?
All right.
We'll get into the 11 human factors presentation please.
l 12 MR. GALLETTI:
Good morning.
My name is Greg I
13 Galletti; I'm a Human Factors engineer in the Division of f3
,b 14 Reactor Controls and Human Factors, a part of NRR here at i
15 the Nuclear Regulatory Commission.
16 I've been asked to come and present some of 17 the Human Factors' findings from a comparison of the two 18 events.
In doing so, I would like to address three basic 19 areas.
The first will be -- I will present a framework 20 for how we did this analysis of comparison.
21 The second area will be a discussion of the 22 significant findings from that comparison, and I will wrap 23 up by giving a short presentation on what the NRC did in 24 terms of human performance as a result of these findings.
gm()
25 The framework you have before you is an i
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON. D.C. 20005-3701 (202) 234-4433
567 1
illustration that we put together to give you a better
~3 2
understanding of the different areas that may affect human
~'
3 performance of an operator during an event.
The genesis 4
of this particular framework is really from two programs 5
we have at the NRC.
6 One is called the Human Factors Information 7
System, which is a database that we maintain in NRR, where 8
we characterize events and operating occurrences, and we 9
put those events into the database for further analysis, 10 The second prog.am that we used for this 11 framework is called the Human Performance Investigation 12 Process, or HPIP.
And that's a protocol that we've 13 developed at NRC that allows an inspector to go out and
/
.I
\\
'w
/
14 actually do a review of an event and look at certain 15 aspects from a human performance perspective and get a 16 better understanding of what characteristics were involved 1
17 in the event that may have affected human performance.
18 If you look at the framework, I wanted to 19 segment this into three basic areas for ease-of-use.
The 20 first would be basically administrative controls and 21 programmatic aspects that affect conduct of operations.
22 Typically those would be training as well as 23 administrative controls.
3 24 Training, as you've heard before, would be w
()
25 things like licensed operator requalification, initial NEAL R. GROSS COURT REPORTERS AND THANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D C. 20005 3701 (202) 234-4433
G68 1
training, on-the-job training, just-in-time training 2
aspects.
Administrative controls would '.ypically be 7-(J 3
administrative and operating procedures, any management 4
standing crders, night orders, that sort of thing.
5 In addition, we have what we call facility 6
conditions and human system interface.
These are 7
typically the hardware plant issues.
Under facility 8
conditions we typically looked at any equipment that was 9
out of service prior to or during the event which may have 10 had an impact.
A look at characteristics such as 11 lighting, humidity, temperature, noise -- that may have 12 affected operator performance.
13 Under human system interface, typically we (D
(/
14 would look at the actual man-machine interface, the 15 control boards themselves -- displays, controls, alarms, i
16 and feedback mechanisms -- in place to allow the operators 17 to understand, were their actions correct, what equipment 18 may or may not be functioning as desired.
19 A second aspect we looked at is really command 20 control communications, crew dynamics, and operator And 1-11 characterize these as really looking at 21 errors.
22 the characteristics of the crew themselves.
23 Under command control communications -- that's 24 pretty straightforward -- we would look at the conduct of
(
\\
l 25 operations-type procedures, what's expected of the s_/
HEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 234-4433 1
l 569 1
operation in terms of 3-way communications.
Under command
,-s 2
we would look at the command structure of the crew,
/,
T 3
understand who's responsible for licensed operator 4
activities.
5 Under crew dynamics, typically we would look 6
at the complement of the crews, look at their familiarit.y 7
with each other, whether chis is a new crew or a 8
longstanding crew.
And then under operator errors we 9
would typically look at errors of omission and commission 10 and how they may have affected the event itself.
11 And the final area we typically look at has to 12 do with management and organization:
that would be 13 planning and scheduling, operational experience self-rs t'ws 14 assessment, and management itself.
Under management we 15 would typically look at management direction and oversight 16 for particular events or particular plant operations.
17 Under operating experience we would get back 18 into whether they had prior history with failures of this 19 type, what were their corrective actions, were their self-20 assessments appropriate and valid, and did they actually 21 correct the situation so it would not occur again.
22 And then under planning and scheduling, 23 typically we would look at issues like work package 24 generation, are they in a condition like an LCo, and any
,/ 8
(_)
25 overtime issues that may have affected the crew NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 034-4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
570 1
themselves.
n 2
MEMBER KRESS:
Are these like inputs to a
\\
~
3 computer program?
4 MR. GALLETTI:
Most of these are mapped to 5
like HFIS which I mentioned, it's Human Factors 6
Information System -- it's a database we --
7 MEMBER KRESS:
Just a database --
8 MR. GALLETTI:
-- maintain.
Right.
Now what 9
we would do is, we would take the findings and 10 observations from an inspection report like this, code 11 them according to the coding scheme we have for HFIS which 12 is very similar to this --
13 MEMBER KRESS:
I see.
O l
\\
()
14 MR. GALLETTI:
-- and then we maintain that 15 database for further analysis and review.
16 MEMBER KRESS:
Okay.
And it's this further 17 analysis and review you try to put -- quantify some of 18 this and --
19 MR. GALLETTI:
Yes.
Typically we get 20 frequency information -- how many times a particular plant 21 may have experienced a problem in a certain area -- or we 22 can do pairwise comparisons with different plants, 23 correct.
24 With this framework in mind, what we did is,
/m
(
25 we basically mapped the findings and observations from the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N V'.
(202) 234 4433 WASHINGTON D C 20005-3701 (202) 234-4433
571 1
two inspections.
And I would like to provide for you 2
basically a summarization of that mapping and our
\\
)
3 conclusions.
4 Before you, you have this table, and 5
essentially what we did is, by mapping the findings and 6
observations, discussion consultation with the team 7
members, we determined what the most significant causes 8
were, or contributing factors were from a human 9
performance aspect, as they affected these two events.
10 From the slide you could see that four primary 11 areas were determined to be most significant.
They were:
12 command, control, communications; training; management and 13 organization; and operating experience /self-assessment.
(p l
\\_/
14 As you will also see, for each of the 15 different events, the impact or influence these four 16 significant factors had, varied greatly.
For instance, in 17 the area of Zion as Mark presented in great detail, the 18 issues of command, control, and communications was the 19 most significant and influential factor that affected the 20 event as it portrayed.
21 Just to be a little bit more specific, you can 22 see we have several generalizations about the 23 characterization of those events, observations.
The loss 24 of the big picture by the shift engineer and the Unit n
()
25 supervisor in controlling the evolution, etc.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D C, 20005-3701 (202) 234-4433
572 1
For Clinton, however, we didn't see very much s
2 of a concern in the command, control, communications area.
3 The most significant and influential factor for Clinton we 4
determined, was really in the management and 5
organizational structure; specifically in issues where 6
management actually condoned and had standing orders which 7
allowed for deviation from procedures; actions that were 8
driven by power production as opposed to safety, as Jeff 9
recently pointed out.
l 10 And then a lack of sensitivity to removing 11 certain barriers to good plant performance, which were 12 identified from the previously, prior to the event.
13 In addition to these two most influential
,\\
/
i
\\m /
14 characteristics for each of the events, both training and 15 operating experience and self-assessment were major 16 contributors and common to both of the two different 17 events.
As was mentioned in training, failure to provide 18 just-in-Cime training on these two evolutions for both of 19 the units played an important role in the event.
20 The failure to provide adequate training when 21 there were certainly known deficiencies in performance; 22 that is, deficiencies in communications standards and 23 reactivity manasument, for example, at Zion, which were 24 known prior to the event, and the licensee had not taken (q
,)
25 the opportunity to train the crew that was on shift during NEAL R. GROSS COURT REPORTERS AND TRANSCR!BERS 1323 RHODE ISLAND AVE., N.W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234-4433 l
l
573 1
the event in those two performance weaknesses, n
2 MEMBER FONTANA:
Simulator fidelity means lack
(
)
3 of simulator fidelity?
You have an "X"
over there?
4 MR. GALLETTI:
In this case, yes.
For this 5
particular example, the flow instrument that Jeff was 6
mentioning that capped out at 7.99 --
7 MEMBER FONTANA:
Oh, yes, that's right.
8 MR. GALLETTI:
The simulator did not have that 9
same capping or deficiency.
So it may have provided some 10 negative training to the operating crew and therefore they 11 didn't understand the limitation on that actual component.
12 MEMBER KRESS:
Is this process in database and t'
13 computer program you have, used in the SALP process or in e
V 14 the senior management meeting process?
e 15 MR. GALLETTI:
Yes it is -- you must be 16 clairvoyant.
My next slide will get into that.
17 CHAIRMAN SEALE:
Where does this polyglot or 18 pick-up nature of this particular crew mix map into this 19 thing?
20 MR. GALLETTI:
What we determined basically, 21 was the crew mix or whether they had -- familiarity with 22 each other -- was not one of the most significant aspects 23 of the events as it played out for both Zion and Clinton, 24 although they were contributing factors, That is, it was C) 25 interesting to note in the case of Clinton, that it was a NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(2 0 ) 234-4433 WASHINGTON, D.C-20005-3701 (202) 234-4433
574 1
brand new crew if you will; that they hadn't had prior fs 2
experience.
What actually transpired during the event
()
3 that was significant, really didn*t map directly back to 4
the fact that it was a new organization.
Other, more 5
overriding factors --
6 CHAIRMAN SEALE:
If it had, where would you 7
put it?
8 MR. GALLETTI:
It wouldn't have been on one of 9
these four.
It would have gone back -- if you look at the i
10 previous slide under crew dynamics 11 CHAIRMAN SEALE:
- Fine, that would have been 12 my -- that's where I would have put it, and I was just I
13 wondering whether or not I was reading that correctly.
'\\~/)
14 MR. GALLETTI:
Yes, you would have; that's 15 correct.
As a result of the events themselves, several 16 actions had been taken as you've already heard from both 17 Jeff and Mark.
In addition, certain actions were taken, 18 directed at the human performance aspects.
19 In both cases there were follow-up inspections 20 conducted at Zion and Clinton which focussed more at 21 Clinton on trying to determine the causes of repetitive 22 failures in the human performance / operator performance, 23 and that was conducted I believe, back in March of
'97.
24 For Zion, we had a follow-up inspection
/N
()
25 directly after the AIT which was the venue for getting NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHOCE ISLAND AVE., N.W, f
(202) 234-4433 WASHINGTON, D.C. 20005 3701 (202) 234-4433
575 1
better description and determination of some of the causes 73 2
of events and putting those causes into a regulatory
'"]
3 compliance framework.
4 MR. DAPAS:
I think the follow-up inspection 5
at Zion was really focused on looking at the enforcement 6
aspects.
Tha augmented inspection team looks at the 7
circumstances surrounding events, develops findings and 8
conclusions, but doesn't look at enforcement, per se, in 9
the follow-up inspections to determine if there were any 10 violations that existed.
11 MR. GALLETTI:
In addition to the follow-up 12 inspections, the information that was generated from the 1
13 event reports were captured in the programmatic elements j%.
b')
14 of the human performance and human reliability of 15 implementation plant.
Specifically program 5 of that plan 16 would require that data be entered into the Human Factors 17 Information System, which I've mentioned before, and in 18 fact, that has been done.
19 That data -- and this really addresses your 20 question -- that data has been analyzed on a semi-anr.ual 21 basis and information from that database is incccporated 22 into a human factors information packet that's provided to 23 senior managers as part of their senior management meeting 24 pre-brief.
rw
)
25 MEMBER KRESS:
Can I access that system on the NEAL R. GROSS COURT REPORTERS AND TRANSCIJBERS 1323 RHODE ISLAND AVE,, N W.
(202) 234-4433 WASHINGTON, D C. 00005-3701 (202) 234 4433
576 1
Internet?
2 MR. GALLETTI:
We are actually working on (q) 3 that; that's one of my tasks, to actually get that to 4
function on the Home Page for the Human Factors group, 5
yes.
6 MEMBER KRESS:
How about this computer program 7
that you mentioned?
9 MR. GALLETTI:
Well, the computer program 9
itself is HFIS --
10 MEMBER KRESS:
On, that is the program?
11 MR. GALLETTI:
It's the database -- right.
It 12 has some sort and search functions to it.
13 MEMBER KRESS:
Sort and search, ps 14 MR. GALLETTI:
Yes.
15 CHAIRMAN SEALE:
At what point -- exactly 16 where is the nexus between this and the PRA activities?
17 How do we try to bring this around to something that's --
18 can be used in integrating human factors activities or 19 human factors concerns, into our risk assessment?
20 MEMBER FONTANA:
Could I extend the question 21 to how does this relate the senior management meeting --
22 MEMBER APOSTOLAKIS:
You'11 notice these are 23 the --
24 MR. GALLETTI:
Let me try to address yours (3
Q) 25 very briefly and then I'll see if Research can provide c
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
577 1
that.
The information from these sorts of events, as I 2
mentioned, are factored into the human performance and g3O 3
human reliability implement.o. ion plan.
Program 2 of tr.at 4
plan -- development of the human model there -- was based 5
on that ATilENA model.
The way that data is entered into 6
ATi!ENA and how it's actually used, we would have to get 7
our Research counterparts to discuss.
8 CllAIRMAN SEALE:
Okay, that's where the Greeks 9
come in though?
10 MEMBER BARTON:
The ATHENIANS.
The Athenian 11 missed that comment.
12 MEMBER FONTANA:
The reason I raised that, as 13 you know, Edward Deming years ago, was pretty adamant
(
)
'v' 14 about blaming the person when a lot of times the system is 15 set up such that there's an outage waiting to happen, 16 regardless of where it was.
27 And I look at these things, the chart thet you 10 have here.
Almost all of thote relate to a management 19 system that wasn't set up properly.
20 MR. GALLETTI:
That is correct.
21 MEMBER FONTANA:
That's why I ask, how does 22 this relate to the senior management meeting system where 23 they have -- we talked only yesterday or the day before --
24 icthere they said, well we really don't rate management.
!n) 25 MEMBER APOSTOLAKIS:
We don't what?
NEAL R. GROSS COURT REPORTERS AND TRANSCR!BERS 1323 RHODE ISLAND AVE, N W.
(202) 234 4433 WASHINGTON. O C. 20005 3701 (202) 234-4433
578 1
MR. GALLETTI:
Let me pass that one on to 2
Cecil Thomas, my deputy director.
3 MR. Ti!OMAS:
Cecil Thomas, deputy director of 4
the Division of Reactor Controls and lluman Factors.
I'd 5
like to break the question, the PRA question and the 6
senior management question into two parts -- for the 7
purposes of this answer, anyway.
8 For the senior management meeting process, the 9
iluman Factors Assessment Branch does a run on the lluman 10 Factors Information System and analyzes the data that are 11 compartmentalized in roughly the categories that Greg 12 showed you.
13 What we do is look at numbers of events, or n
V) 14 numbers of actual hits, involving human performance in 15 those areas, that we get both from LERs and from 16 inspection reports.
We compare the number for a given 17 plaat with the national average
-- more specifit. ally, two 18 times the national average -- if a particular facility's 19 human performance attributes exceed twice the national 20 average.
21 We do an in-depth ana3ysis similar to what 22 Greg did here for these two events and tried to explain in 23 a report that we provide to the senior managers, what our 24 assessment of the situation is.
Ci j
25 The way the senior managers use this it's v
N EAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N.W.
(202) 234-4433 WASHINGTON. D C 20005 3701 (202) 234-4433
579 1
true, the other day Joe and Sam briefed you on some of the n
2 elements of the senior management meeting process.
This k) 3 information is used as insight.
It's not used directly to 4
make decisions but it'a used for insight in trying to 5
better understand things that are probably more tangible.
G As far as use of this information in risk 7
assessment space, Jay Persensky from the Office of 8
Research is here and is prepared, as I understand it, to 9
talk about that in a little more detail.
10 MEMBER BARTON:
That's fine.
l 11 MEMBER APOSTOLAKIS:
How many presenters do we 12 have this morning?
13 MEMBER BARTON:
This is it.
/~T iU 'i 14 CHAIRMAN SEALE:
These are them.
15 MEMBER APOSTOLAXIS:
Human factors.
I didn't 16 know that.
17 MR. PERSENSVsY:
Good morning.
My name is Jay 18 Persensky.
I'm from the Office of Research and I was 19 asked to come hare in anticipation of such a question so 20 it wa ti really a planned presentation.
I don't have 21 MEMBER APOSTOLAKIS:
The question never came, 22 though, did it?
23 MR. PER$ ENSKY:
Yes, it did.
I've asked the 24 question.
It's just that it was probably going to be
(')%
25 coming from you instead, NEAL R. GROSS COU AT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WApuNGTON, D C. 20005 3701 (202) 234-4433 m
l 580
)
I 1
CHAIRMAN SEALE:
I'm an easy mark.
2 MR. PERSENSKY:
Just very quickly, as Greg
,y
(
)
3 mentioned, the way this relates or any of event of this 4
magnitude, or these events relate to the program planner 5
and program implementation, is through the ATHENA model.
6 It's in the program plan which will be discussed next 7
month at your meeting.
8 We're still in the developmental stages of 9
this particular model, this particular activity.
But to 10 address one of the issues that was raised about, sometimes 11 people are set up; it's not really always the people, this 12 is the current ATHENA model framework and the error 13 forcing context box here is the part of that in terms of,
[m
\\
ks) 14 how people may be set up.
It's a combination of not only 15 the people but also the plant conditions and the 16 conditions from the performance shaking factor.
17 MR. MARKLEY:
Jay, could you speak a little I
38 closer to your mike?
19 MEMBER MILLER:
You're going to relate these 20 particular situations to this model, then?
Is that how 21 we're going to do this?
22 MEMBER APOSTOLAKIS:
Not today, I hope.
23 MR. PERSENSKY:
No, I'm not prepared -- good 24 point in fact, because we have not done it.
I'm just (3) 25 going to give you sort of a general overview as to how it NEAL R. GROSS CoVRT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D C. 20005 3701 (202) 234-4433
581 1
would be incorporated.
MEMBER APOSTOLAKIS:
Yesterday we had a long f ')
!'~'
3 discussion about the senior management meeting and what 4
does it mean to have a model and all that.
There's a 5
beginning of a model.
6 If the senior management meeting come up with 7
something like this, and go say, to the end there and say, 8
risk management decision -- SMM decision -- and then 9
somehow show us what are the principal factors, how the 10 boxes are related.
That's what I mean.
I'm not talking 11 about 12 CHAIRMAN SEALE:
Rocket science.
l 13 MEMBER APOSTOLAKIS:
No, this is better than
,_s\\
/
{
14 rocket science.
Let's try something else.
15 MEMBER BARTON:
We understand your model 16 concept now, George.
Go ahead, Jay.
17 MR. PERSENSKY:
Okay.
Again, this is just to 18 give you a reminder of the model.
This comes directly 19 from NUREG/CR-6350, which I'm sure you probably have more 20 copies of than you ever want to read again -- and you'll 21 probably ask for them again, i
22 But this describes the development of ATHENA l
23 and the basis for it.
The process described in that 24 document for incorporating information such as the
/~T
(_,)
25 information from these events, is in Figure 3-1 of that NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 13.73 RHODE ISLAND AVE, N W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) ?34 4433
582 1
document.
2 As you can see, there's two parts really to my
(
\\'J 3
answer, and I'm nort of jumping ahead.
One is, the first 4
thing is there is a -- I hate to call it a database; it's 5
more of a knowledge or information base -- that's being G
developed for the purposes of human reliability at the 7
ATHENA database at this point.
Which has very few events 8
in it; we're just beginning to look at it.
9 It's a knowledge-base because it's very 10 descriptive and not one that's based on just counting 11 elements.
But it has an in-depth description of what's 12 going on.
It is developed from things like an AIT report, 13 any report from investigations or from a utility we might i
)
\\>
14 have, that has an in-depth description of what went on, 15 especially if there's any in-depth description of human 16 behavior in that.
17 There are probably I think, only like 12 18 events from the past that are currently in that 19 information base.
Events like these may very well be --
20 like these two -- might very well be incorporated in that.
21 We're just beginning a new contract in that area and 22 setting up criteria as to what should go into this 23 information base.
24 From the perspective of PRA though, and how (3
i
)
25 ATHENA and this kind of information is used, you can see x
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE., N W.
(202) 234-4433 WASHINGTON, D C. 20005 3701 (202) 234-4433
583 1
from this flow diagram that you have to have both the 2
accident scenario information, the human factors errors, 7-3 you have to identify unsafe acts, go through this 4
cherscterization of the error force and context.
5 There's a loop through to make sure that all G
the information from the PRA model which is essentially --
7 to it, eventually then you move into the estimating 8
frequency of error forcing context, the human factors 9
errors, and then you would put it into the actual 10 calculation of the PRA.
So this is just a general 11 description of how --
12 MEMBER APOSTOLAKIS:
This is several years 13 from --
t\\m /
14 MR. PERSENSKY:
Yes.
We're not there yet.
We 15 have done -- in fact we're doing currently, there is a 16 pilot test going on at Seabrook where the utility has 17 volunteered to participate with us in trying to apply this 18 to their PRA.
So again, this is the general process that 19 we --
20 dEMBER APOSTOLAKIS:
I think ATHENA is 21 becoming now a central part of what you guys are doing, 22 plus you are using it in the -- identifying research 23 needs, right, in the human performance program plan.
The 24 essence of it, the basic structure is ATHENA and then you (A,)
25 identify what you need to do?
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS I
1323 RHODE ISLAND AVE., N W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 2344433
584 1
MR. PERSENSKY:
We are using it an a framework 2
in our consideration for how we prioritize and select g
3 efiorts for both research and how it fits -- how those 4
programs fit with the program office's requirements needs.
5 MEMBER APOSTOLAKIS:
We had a -- I think it 6
was a half-a-day presentation to the Human Factors 7
subcommittee 8
MR. PERSENSKY:
Yes.
9 MEMBER APOSTOLAKIS:
several months ago?
10 MR. PERSENSKY:
Right.
11 MEMBER APOSTOLAKIS:
Given the importance that 12 the staff has given to ATHENA, do you think that we should l
13 have a briefing soon so at least because at that time I ID V
14 don't think that you got any comments out of the 15 subcommittee or the committee.
And I'm a little bit 16 concerned that ATHENA now is becoming too important.
It 17 hac not been reviewed by this committee in a serious way.
18 VICE CHAIRMAN POWERS:
George, I think we need 19 to get together on the Human Performance Program Plan 20 revisions that we've just gotten.
21 MEMBER APOSTOLAKIS:
Yes, but then what do you 22 do?
You discuss the ATHENA also in that context?
23 MEMBER BARTON:
Sure, sure.
It's a piece of 24 that.
()
25 VICE CHAIRMAN POWERS:
I think -- I mean, I NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234-4433 WASHINGTON, D C. 20005-3701 (202) 234 4433
585 1
like you, find great appeal in this model and I think it fm 2
can be used to offer some suggestions on the Program Plan.
3 MEMBER APOSTOLAKIS:
See, if you want to 4
discuou the essence of ATHENA then you bring different 5
people here, right?
Because --
6 MR. PERSENSKY We would probably have the 7
same people, just a little bit expanded.
Because the 8
people that are working on ATHENA are part of the crew 9
that is also working on the Plan.
l 10 CHAIRMAN SEALE:
Yes, I think the context l
11 relationships are a little clearer, too, when you have the 12 Plan there with ATHENA.
13 MR. PERSENSKY:
Again, we -- as I described in U
14 that meeting, we're using ATHENA in two different ways 15 here.
One is that it is in fact, a tool for human 16 reliability analysis, but it's also, because of its 17 structure, we're using it as a framework for making la decisions on the incorporation.
19 CHAIRMAN SEALE:
A template.
20 MR. PERSENSKY:
Yes, a template -- we keep 21 using different terms for essentially the same thing.
22 It's the categories.
2?
MEMBER BARTON:
George is trying to pin us 24 down to a date for briefing already on ATHENA, right?
Q(%
25 MEMBER APOSTOLAKIS:
I'm trying to understand NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISt.AND AVE, N W.
(202) 234-4433 WASHINGTON, D.C. 20005 3701 (202) 234-4433 i
- i...
586 1
here, what's going on.
The thing is becoming too big end it has not really -- I'm not even sure that all of us c) 3 around the table are familiar with it.
There was a 4
subcommittee briefing, half-a-day --
5 MR. PERSENSKY:
We're going to have a full 6
committee briefing on the Plan at your next meeting in 7
October.
8 MEMBER APOSTOLAKIS:
I meant something more 9
serious, though.
Maybe a day or two.
10 CHAIRMAN SEALE:
George, they're always 11 serious.
12 MEMBER BARTON:
George, I think we'll have to 13 look at that and see if we can schedule that in and not V
14 t.y to get ATHENA --
15 MEMBER APOSTOLAKIS:
A subcommittee meeting --
16 MEMBER BARTON:
-- in this briefing.
where timing issues 17 MEMBER APOSTOLAKIS:
18 are not that important.
You know, I mean an hour-and-a-19 half is an hour-and-a-half.
20 VICE CHAIRMAN POWERS:
George, I think what 21 they're hinting is that we can discuss this --
22 MEMBER BARTON:
We can discuss this at another 23 meeting.
24 MEMBER APOSTOLAKIS:
But I want to know his
,~
j 25 opinion.
When do you think you're going to be ready?
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234-4433 WASHINGTON, D C. 20005 3701 (202) 234 4433
587 1
Because they are doing this thing with Seabrook, n
2 VICE CilAIRMAN POWERS:
Again, I think we can I
)
3 do this --
4 MEMBER APOSTOLAKIS:
You can do it now --
5 VICE CilAIRMAN POWERS:
-- offline, George.
6 MEMBER APOSTOLAKIS:
What?
7 VICE CllAIRMAN POWERS:
I think we can do this 8
offl.ine, j
9 MEMBER BARTON:
Jay will let you know when l
10 he's ready, George.
l l
11 MEMBER APOSTOLAKIS:
That's why I want the 1
12 subcommittee meeting.
I'm Chairman of that.
13 MEMBER BARTON:
At this point, are there any
(^N k.
14 comments the licensees would like to make on the 15 presentations of either event?
llaving none, are there any 16 further questions of members of the committee of any of 17 the presentations?
18 Hearing none, I'd like to thank the staff for 19 its detailed, comprehensive presentation, and also 20 licensees for attending today's briefing.
At this point 21 Bob, I'll turn the meeting back over to you.
22 CHAIRMAN SEALE:
I'd like to also thank the 23 licensees.
I know this hasn't been one of the really 24 exciting times in your life in a positive sense, but we do
(
)
25 appreciate your coming to see us and sharing with us your NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE N W.
(202) 234 4433 WASH:NGTON, O C 20005-3701 (202) 234-4433 9
588 1
insights on this.
,q I think the staff has given us a very nice 2
ii 3
overview of the process in the context that we wanted --
4 not a war story or two separate war stories, but rather an 5
integrated, human factorn assessment of the role that that 6
played in these two events.
And I want to thank you very 7
much for, obviously the thought that went into meeting 8
that particular need.
9 With that in mind, and again, thank you very 10 much, I'm going to now remind the committee members the 11 first order of business when we get back is the 12 reconciliation of ACRS comments; that's file 20 if you 13 will.
And be ready to do it, so if you don't think you o
's.s)
I 14 have anything to do in the next 18 minutes, you do.
15 MEMBER BARTON:
You're telling us to work on 16 our break, right?
17 CHAIRMAN SEALE:
Work on the break, and we'll 18 resume at a quarter of.
19 (Whereupon, the Open portion of the 444th ACRS 20 Meeting was concluded at 10:32 a.m.)
21 22 23 24 AQ, 25 NEAL R. GROSS COUhT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVE, N W.
(202) 234 4433 WASHINGTON, D C. 20005-3701 (202) 234-4433
O CERTIFICATE This is to certify that the attached proceedings before the United States Nuclear Regulatory Commission in the matter of:
Name of Proceeding: 444" ACRS Docket Numbert N/A Place of Proceeding: ROCKVILLE, MARYLAND were held as herein appears, and that this is the original transcript thereof for the file of the United States Nuclear Regulatory Commission taken by me and, thereafter reduced to O
1 typewriting by me or under the direction of the court reporting company, and that the transcript is a true and I accurate record of the foregoing proceedings.
ft1
'7) A V6RIIETT RINEli' official Reporter Neal R. Gross and Co., Inc.
i O
NEAL R. GROSS COURT REPORTERS AND TRANSCRIDERS 1323 RilODEISLAND AVENUE,NW (202)234-4433 WASi!INGTON, D C, 20003 (202~ 2344433
INTRODUCTORY JTA'4EMENT BY THE ACRS CHAIRMAN 444TH ACRS MEETING, SEPTEMBER 3-5, 1996
(~
t
/
THE MEETING WILL NOW COME TO ORDER.
THIS IS THE THIRD DAY OF THE 444TH MEETING OF THE ADVISORY COMMITTEE ON REACTOR SAFEGUARDS.
DURING TODAY'S MEETING, THE COMMITTEE WILL CONSIDER THE FOLLOWING:
(1)
OPERATING EVENTS INVOLVING IMPROPER CONTROL ROD MOVEMENT DURING SHUTDOWN AT ZION UNIT 1, AND NONCONSERVATIVE OPERATIONS DURING ISOLATION OF RECIRCULATION PUMP SEAL LEAK AT THE CLINTON NUCLEAR PLANT (2)
RECONCILIATION OF ACRS COMMENTS AND RECOMMENDATIONS (3)
REPORT OF THE PLANNING AND PROCEDURES SUBCOMMITTEE (4)
PREPARATION OF REPORTS PORTIONS OF TODAY'S MEETING MAY BE CLOSED TO DISCUSS ORGANIZATIONAL AND PERSONNFL MATTERS THAT RELATE SOLELY TO THE
/
INTERNAL PERSONNEL RULES AND PRACTICES OF THIS ADVISORY COMMITTEE V
AND MATTERS THE RELEASE OF WHICH WOULD REPRESENT A CLEARLY UNWARRANTED INVASION OF PERSONAL PRIVACY.
THIS MEETING IS BEING CONDUCTED IN ACCORDANCE WITH THE PROVISIONS OF THE FEDERAL ADVISORY COMMITTEE ACT.
MR. SAM DURAISWAMY IS THE DESIGNATED FEDERAL OFFICIAL FOR THE INITIAL PORTION OF THE MEETING.
WE HAVE RECEIVED NO WRITTEN STATEMENTS OR REQUESTS FOR TIME TO MAKE ORAL STATEMENTS FROM MEMBERS OF THE PUBLIC REGARDING TODAY'S SESSIONS.
A TRANSCRIPT OF PORTIONS OF THE MEETING IS BEING KEPT, AND IT IS REQUESTED THAT THE SPEAKERS USE ONE OF THE MICROPHONES, IDENTIFY THEMSELVES AND SPEAK WITH SUFFICIENT CLARITY AND VOLUME SO THAT THEY CAN BE READILY HEARD.
(O v
o o
p# o ACRS PRESENTATION ON OPERATING REACTOR EVENTS SEPTEMBER 5,1997 Introduction Robert L Dennig, Acting Branch Chief Events Assessment and Generic Communications Branch, DRPM, NRR (301)415-1156 Zion, Unit 1 Marc L Dapas, Acting Deputy Director Division of Reactor P.Geis, RIII (630)829-9601 Clinton Geoffrey C. Wright, Branch Chief Division of Reactor Pr@a, RIII (630)829-9602 i
Human Performance Greg S. GaNetti, Human Factors Engineer l
Human Factors Ass =+.st Branch, DRCH, NRR (301)415-1831 i
h l
O O
~~ O
~
ZION, UNIT 1 IMPROPER CONTROL ROD MOVEMENTS PRESENTATION BEFORE THE ADVISORY COMMITTEE ON REACTOR SAFEGUARDS BY MARC L. DAPAS ACTING DEPUTY DIRECTOR DIVISION OF REACTOR PROJECTS REGION 111 (630) 829-9601 SEPTEMBER 5,1997
O O
~O
~
PROBLEM UNAUTHORIZED REACTOR STARTUP:
e A LICENSED REACTOR OPERATOR WAS DIRECTED TO REDUCE POWER TO THE POINT-OF-ADDING-HEAT PER A STEP IN THE SHUTDOWN PROCEDURE. HE DID NOT UNDERSTAND HOW TO EXECUTE THE STEP AND CONSEQUENTLY INSERTED CONTROL RODS CONTINUOUSLY MAKING THE REACTOR SUBSTANTIALLY SUBCRITICAL. INSTEAD OF STOPPING, EVALUATING, AND COMMUNICATING THE UNAUTHORIZED CHANGE IN REACTIVITY, THE OPERATOR CONTINUOUSLY WITHDREW RODS IN AN ATTEMPT TO TAKE THE REACTOR CRITICAL AND RE-ESTABLISH POWER AT THE POINT-OF-ADDING-HEAT.
O O
~
~O ROOT CAUSES e
BREAKDOWN IN COMMAND AND CONTROL BY OPERATIONS SUPERVISION.
e INADEQUATE COMMUNICATIONS BETWEEN OPERATORS, OPERATIONS SUPERVISION, OPERATIONS MANAGEMENT, AND NUCLEAR ENGINEERING DEPARTMENT PERSONNEL.
e THE FAILURE TO PRE-PLAN THE SHUTDOWN EVOLUTION.
e THE FAILURE OF OPERATIONS SUPERVISION AND PLANT MANAGEMENT TO PROVIDE CLEAR DIRECTION TO THE OPERATING CREW REGARDING THE PLANNED SHUTDOWN.
e THE EXISTENCE OF A NUMBER OF CONTROL ROOM DISTRACTIONS DURING SHIFT ACTIVITIES.
e LICENSED OPERATOR TRAINING DEFICIENCIES.
3
SAFETY SIGNIFICANCE ACTUAL EVENT DID NOT POSE A RISK TO THE HEALTH AND SAFETY OF THE PUBLIC, HOWEVER, THE EVENT WAS SAFETY SIGNIDCANT FROM A HUMAN PERFORMANCE PERSPECTIVE.
SEQUENCE OF EVENTS 2/19
~ 12:00 P.M.
CONTAINMENT SPRAY PUMP DECLARED INOPERABLE. FORTY-EIGHT HOUR TECHNICAL SPECIFICATION LCO ENTERED.
2/21 7:00 A.M.
NEW OPERATING CREW BEGINS FIRST DAY OF SHIFT DUTY AFTER THREE DAYS OFF.
2/21
~ 7:00 A.M.
MAIN FOCUS OF SHIFT TURNOVER BRIEFING IS THE RESTORATION OF THE 1C CONTAINMENT SPRAY PUMP TO AVOID A REQUIRED SHUTDOWN OF UNIT 1.
4
i O
O
~
~O 2/21 9:30 A.M.
NUCLEAR ENGINEERING SUPERVISION ATTEMPTS TO ARRANGE A BRIEFING WITH OPERATIONS SUPERVISION TO DISCUSS REACTIVITY MANAGEMENT DURING SHUTDOWN.
BRIEFING NOT CONDUCTED DUE TO LACK OF SUPPORT FROM SHIFT ENGINEER AND UNIT SUPERVISOR.
2/21 10:40 A.M.
FORTY-EIGHT HOUR LCO EXPIRES AND THE LICENSEE ENTERS A FOUR-HOUR SHUTDOWN ACTION STATEMENT.
5
O O
^
O 2/21
~ 11:00 A.M.
INFORMAL DISCUSSION HELD BETWEEN PLANT MANAGEMENT, OPERATIONS MANAGEMENT, AND OPERATIONS SUPERVISION REGARDING THE STATUS OF THE CONTAINMENT SPRAY PUMP.
INADEQUATE COMMUNICATIONS RESULTS IN DIFFERENT UNDERSTANDINGS OF WHEN TO ABANDON CONTAINMENT SPRAY PUMP RESTORATION EFFORTS AND INITIATE SHUTDOWN.
2/21 11:10 A.M.
FORMAL SHUTDOWN BRIEFING - FOCUSES ON REACTIVITY MANAGEMENT TO SUPPORT A QUICK RETURN TO POWER.
2/21 12:09 P.M.
OPERATORS BEGIN REDUCING POWER AT A QUARTER PERCENT POWER PER MINUTE.
6
O O
~
'O 2/21
~ 12:55 F.M.
LICENSEE IDENTIFIES THAT THE CONTAINMENT SPRAY PUMP SHOULD HAVE BEEN DECLARED INOPERABLE AT 10:20 A.M.
VICE 10:40 A.M. ON FEBRUARY 19.
CONSEQUENTLY, PLANT S AUTDOWN REQUIRED BY 2:20 P.M. VICE 2:40 P.M. -
RATE OF POWER REDUCTION INCREASED TO A HALF PERCENT PER MINUTE.
2/21-
~ 2:04 P.M.
UNIT 1 AT 7 PERCENT POWER.
SHIFT ENGINEER INSTRUCTS UNIT SUPERVISOR TO MAINTAIN THE REACTOR CRITICAL DUE TO THE EXPECTED RETURN OF THE CONTAINMENT SPRAY PUMP.
7
UNIT SUPERVISOR READS SHUTDOWN PROCEDURE STEP PERTAINING TO ESTABLISHING POWER AT OR BELOW THE POINT OF ADDING HEAT.
PRIMARY NUCLEAR STATION OPERATOR (NSO) ASKS UNIT SUPERVISOR IF HE WANTS HIM TO DRIVE RODS IN.
UNIT SUPERVISOR SIMPLY REREADS PROCEDURE STEP.
2/21 2:07 P.M.
MAIN TURBINE IS TRIPPED.
UNIT SUPERVISOR READS SHUTDOWN PROCEDURE REGARDING ESTABLISHING POWER AT THE POINT-OF-ADDING-HEAT.
8
PRIMARY NSO ACKNOWLEDGES UNIT SUPERVISORS DIRECTIVE AND INITIATES CONTINUOUS CONTROL ROD INSERTION.
QUALIFIED NUCLEAR ENGINEER (QNE)
OBSERVES EXCESSIVE CONTROL ROD INSERTION AND QUESTIONS THE PGIMARY NSO.
PRIMARY NSO RESPONDS THAT HE IS FOLLOWING HIS PROCEDURE AND CONTINUES TO INSERT CONTROL RODS.
2/21 2:11 P.M.
PRIMARY NSO STOPS INSERTING CONTROL RODS WHEN INTERMEDIATE POWER RANGE INDICATION IS 0.025 PERCENT.
9
O O
~
~O 2/21
~ 2:12 P.M.
PRIMARY NSO OBSERVES THAT POWER HAS l
i DROPPED TO O.01 PERCENT (DUE TO SUBSTANTIAL NEGATIVE REACTIVITY t
l ADDITION FROM ROD INSERTION) AND
}
l INFORMS UNIT SUPERVISOR THAT HE INTENDS TO WITHDRAW RODS TO l
STABILIZE POWER AT 0.025 PERCENT.
j UNIT SUPERVISOR ACKNOWLEDGES l
PRIMARY NSO.
PRIMARY NSO INITIATES CONTINUOUS CONTROL ROD WITHDRAWAL.
/
QNE OBSERVES THAT PRIMARY NSO IS WITHDRAWING CONTROL RODS AND 1
l QUESTIONS HIS ACTIONS - PRIMARY NSO RESPONDS THAT HE IS NOT COMFORTABLE l
WITH WHAT HE IS DOING AS WELL.
4 10 I
O O
~
~O 2/21
~ 2:14 P.M.
SHIFT ENGINEER DIRECTS THE UNIT SUPERVISOR TO TRIP THE REACTOR DUE TO IMMINENT EXPIRATION OF SHUTDOWN ACTION STATEMENT.
2/21 2:15 P.M.
PRIMARY NSO TRIPS THE REACTOR PLACING UNIT 1 IN HOT SHUTDOWN.
2/21
~ 3:08 P.M.
QNE AND LEAD NUCLEAR ENGINEER (LNE)
DISCUSS WITH SHIFT ENGINEER THEIR CONCERNS REGARDING OBSERVED CONTROL ROD MANIPULATIONS DURING UNIT 1 SHUTDOWN.
SHIFT ENGINEER WAS UNAWARE THAT THE REACTOR HAD BEEN SHUTDOWN AND THE PRIMARY NSO HAD ATTEMPTED TO RESTART THE REACTOR.
11
2/21
~ 6:00 P.M.
NUCLEAR ENGINEERS DISCUSS THEIR CONCERNS WITH OPERATIONS MANAGEMENT.
2/22
~ 9:30 P.M.
PLANT MANAGER IS INFORMED THAT A
" PROCEDURE PROBLEM" OCCURRED DURING THE UNIT 1 SHUTDOWN.
THE ACTIONS OF THE PRIMARY NSO ARE NOT DISCUSSED.
12
i l
AUGMENTED INSPECTION TEAM FINDINGS i
l l
e OPERATIONS SUPERVISION DID NOT PROPERLY EXERCISE ITS l
OVERSIGHT RESPONSIBILITIES FOR ENSURING THAT SHIFT j
ACTIVITIES WERE CONDUCTED IN A CONTROLLED MANNER.
i l
NO DIRECTION WAS PROVIDED TO OPERATIONS SUPERVISION l
TO CORRECT THE COMMAND AND CONTROL DEFICIENCIES, j
COMMUNICATION PROBLEMS, LACK OF TEAMWORK, AND CONTROL ROOM DISTRACTIONS WHICH COLLECTIVELY PRECIPITATED THIS EVENT.
THE ACTIONS OF THE PRIMARY NSO REFLECTED A j
SIGNIFICANT LACK OF UNDERSTANDING OF REACTOR PHYSICS AND PROPER CONTROL ROD MANIPULATIONS FOR A l
CONTROLLED APPROACH TO CRITICALITY.
THE SIGNIFICANCE OF THE EVENT WAS NOT COMMUNICATED TO PLANT MANAGEMENT IN A TIMELY MANNER.
13
l e
THE DELIBERATE DECIS!ON BY OPERATIONS MANAGEMENT TO RETURN THE INVOLVED OPERATORS TO LICENSED DUTIES REFLECTED A l_ACK OF APPRECIATION FOR THE SIGNIFICANCE OF THE EVENT.
l e
A NUMBER OF PRECURSOR EVENTS HAD OCCURRED WITH ROOT CAUEFS RELATEi TO POOR COMMUNICATIONS, WEAK COMMAND AND CONTRL)L, AIMD POOR REACTIVITY MANAGEMENT.
e CORRECTIVE ACTIONS FOR THESE PRECURSOR EVENTS WERE INADEQUATE.
l l
e LICENSED OPERATOR REQUALIFICATION PROGRAM WAS DEFICIENT.
t 14 l
i f
l CLINTON PO-WER STATION I
REACTOR RECIRCULATION PUMP SEAL FAILURE l
l PRESENTATION BEFORE THE ADVISORY COMMITTEE ON REACTOR SAFEGUARDS BY GEOFFREY C. WRIGHT l
BRANCH CHIEF l
DIVISION OF REACTOR PROJECTS REGION 111 j
(630) 829-9602 l
SEPTEMBER 5,1997 l
3
_j
9 O
~
'O PROBLEM e
FAILURE OF THE "B" REACTOR RECIRCULATION PUMP SEAL.
CAUSE e
INAPPROPRIATE AND NON-CONSERVATIVE DECISIONS BY LICENSEE SUPERVISION AND MANAGEMENT.
SAFETY SIGNIFICANCE e
SIGNIFICANT DEFICIENCIES IN CONDUCT OF OPERATIONS WERE HIGHLIGHTED.
2
BACKGROUND e
"B" PUMP SEAL HAD A HISTORY OF FAILURES CATASTROPHIC FAILURE OCCURRED IN 1989 WITH A MAXIMUM SEAL LEAKAGE OF ABOUT 63 GPM.
l e
PUMP SEAL PRESSURES INDICATED DEGRADATION FOLLOWING RESTART IN APRIL FOLLOWING TRANSIENT.
LICENSEE ESTABLISHED ADMINISTRATIVE LIMIT AFTER i
OBSERVING O.6 GPM STEP CHANGE IN LEAKAGE IN LATE AUGUST.
r INITIAL CONDITION l
REACTOR AT 100% POWER, WITH UNIDENTIFIED LEAKAGE OF 3.9 GPM.
[
I 3
)
e G
~O
~
PROGRESSION OF EVENT e
SEPTEMBER 5,1996:
BEGAN PREPARATIONS FOR REPLACING PUMP SEAL -
GOING TO SINGLE LOOP OPERATION.
SECURED "B" RECIRCULATION PUMP, CLOSED SEAL STAGING VALVE AND COMPLETED LOOP ISOLATION.
DRYWELL PRESSURETRENDED UP.
DRYWELL LEAKAGE INCREASED - INITIALLY BELIEVED TO HAVE PEAKED AT 2037 AT ABOUT 38 GPM (ACTUAL LEAKAGE LATER DETERMINED TO HAVE BEEN BETWEEN 20 - 30 GPM) 4
.............._.........j
O O
~O e
SEPTEMBER 6,1996:
THE FOUR HOUR SHUTDOWN LCO EXPIRED, THE CREW BRIEFED ON A SHUTDOWN, REACTOR POWER WAS REDUCED TO 23 PERCENT, AND THE REACTOR MANUALLY SCRAMMED.
COMPLICATIONS DURING THE SHUTDOWN - INCLUDED SUPPRESSION POOL LEVEL, ELECTRICAL SWITCHING ERROR AND A REPORTED FIRE.
i 5
I
O O
~
~O ROOT CAUSES e
MANAGEMENT FAILED TO PUT ECONOMIC EXPECTATIONS IN PROPER-FOCUS WITH SAFETY.
EMPHASIS ON MAINTAINING POWER PRODUCTION ATTAINING SINGLE LOOP CONFIGURATION e
PROCEDURAL COMPLIANCE THROUGH INTENT DID NOT ADHERE TO PROCEDURES LICENSEE CORRECTIVE ACTIONS PREPARED AND EXECUTED STARTUP READINESS ACTION PLAN AND STRATEGIC READINESS PLAN.
6
O O
~
~O 1
NRC ACTIONS ESTABLISHED SPECIAL INSPECTION & OPERATIONAL SAFETY TEAM - RESULTED IN ONE SEVEPITY LEVEL ll AND TWO SEVERITY LEVEL lliVIOLATIONS, AND A $350,000 civil PENALTY.
i e
OVERSIGHT PANEL WITH REGION AND NRR MANAGEMENT TO MONITOR LICENSEE'S CORRECTIVE ACTIONS.
l e
AUGMENTED RESIDENT INSPECTOR STAFF.
i b
I 7
l 4
O O
~
~O l
Human Factors Aspects of the Clinton and Zion Events Presented by Greg S. Galletti.
Human Factors Engineer Division of Reactor Controls & Human Factors. NRR Description of analysis framework
- Discussion of significant findings
- Discussion of actions taken
()
()
Hum:n Pcrform:nc ses: ment Areca v
- " "U Administrative Controls Command, Control, &
Communications JL Facility Conditions 1r Crew T
Dynamics EVENT Human Perf.
Human-System Jk interface Pemtor Enom
\\
1t Planning &
Mana.sement Scheduling
& Org; nization Experience /
Self-Assessment
O O
~O
~
l Significant Human Performance Findings-l l
l Clinton Zion Area l
X Command, Control, Communication i
x Lack of management direction i
x Loss of big picture l
x Poor communication of reactor status or concerns with rod movement X
X Training i
x x
Lack of recent simulator exercises on similar evolutions x
x Missed opportunites to address known weaknesses x
Simulator fidelity X
X Management & Organization l
Management condoning procedural deviations x
x Actiores driven by focus on power production x
Lack of sensitivity to removing performance barriers.
l X
X Operating Experience /Self-Assessment Past corrective actions ineffective x
Lack of self-critical assessment x
x x
x Prior operating weaknesses not addressed in timely manner l
i
Use of Human Performance Findings Clinton Zion Actions X
X Follow-up inspections conducted X
X Data integrated into program elements of the Human Performance & Human Reliability i
implementation Plan x
x Data for HFIS t-x x
Input to human performance information for Senior Management Meeting pre-brief i
Pcwer Rocctor Ev ;nt impact'en HP&HRIP Program 1 Program 2 Program 3 Develop the Develop and Foster national and technical basis to update model of support regulatory human intemational dialogue cooperation decisions performance A
EVENT
' ~..
~,g V
Program 4 Program 6 Program 5 Conduct operating Provide support in Support human events aisalysit human perf. & human perf. & human and database reliability for regulated reliability development materials licensees inspection and programs review e
4 e
e
YI Accident h.)
f hh PRA Scenario m
's MFEs Definitions Model Identification &
^
Definitien of pff Seerch processes Plent ldentify experience Unsafe Acts Knowledge-base I
Characterize 4
Screening /
Refinement of Error Forcing 4
Contexts PRA Model I
HFE y
Quentification O
Estimate Step 1 Frequency of Error Forcing saperience Contexts i
Knowledge base v
sten 2 Estimate Probabilities Knowledge base of HFEs v
Integrate with PRA Figure 3.1 ATHEANA applicadon process flow diagram O
NUREG/CR-6350 3-4 1
5 a
i i
i z
o
/
s i
n::t f
i 3
s u
I 4
3 i
Error PRA.
i Forcing 4
Human Error
- Mociel l
)
Context 4
acAty w
Factors j*
m Mamsenance j
j w
a i
g, i
s r
s 4
,i 1
p.cary sc.n.no Gehrdion i
j t
9 l
i 4
~~------- #
i i
t l
I bI o
e e
en
,......-.%.,t
,.,,..,.,.,_,,._._,,._,_...%.g
,...w
.- _,,