ML20236H670
| ML20236H670 | |
| Person / Time | |
|---|---|
| Issue date: | 12/03/1986 |
| From: | Heltemes C NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | Stello V NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO) |
| Shared Package | |
| ML20236H487 | List: |
| References | |
| FOIA-87-377, RTR-NUREG-0090, RTR-NUREG-90 NUDOCS 8708050290 | |
| Download: ML20236H670 (3) | |
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UNITED STATES NUCLEAR REGULATORY COMMISSION
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DEC S 1986 l
J MEMORANDUM FOR:
Victor Stello, Jr.
Executive Director for Operations FROM:
C. J. Heltemes, Jr., Director Office for Analysis and Evaluation of Operational Data 1
SUBJECT:
SECTION 208 REPORT TO THE CONGRESS ON ABNORMAL OCCURRENCES FOR APRIL-JUNE 1986 i
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Enclosed for your signature is a Commission paper which. forwards the subject draft report to the. Commission for approval.
I believe all major issues associated with both the Commission paper and draft report have been resolved.
The Offices of Nuclear Reactor Regulation, Nuclear Material Safety and Safeguards, Nuclear Regulatory Research, Inspection and. Enforcement, State Programs, Public Affairs, and Administration (Division of Security), concur.
All Regional Offices concur.
The Office of the General Counsel has no legal objections.
There are two items which I would like to bring to your attention in regard to l
the enclosed draft report.
j 1.
There was a difference of opinion among the staff as to whether Appendix C, Itein 1 (i.e., "Out-of-Sequence Control Rod Withdrawal at Peach Bottom Unit 3) should be reported as an abnormal occurrence (AC). The different perspectives and their resolution are discussed in Attachment A to this memorandum; in summary, Region 1 now agrees with NRR and AE00 to report the item in Appendix C rather than as an A0.
2.
In the Commission's approval of the first quarter CY 1986 A0 report (reference memorandum from John C. Hoyle, Acting Secretary, to you dated September 24,1986), the Commission stated that the iodine-125 brachytherapy source rupture at the University of Cincinnati Medical Center (a 1984 event which was the subject of our case study AE0D/C601, issued August 1986) should be considered in the next (i.e., second quarter CY 1986) A0 report.
The staff position on this issue (i.e., the event is'a medical misadmin-istration, and therefore is reportable as an A0 unTe'r the guidelines delineated in Part II of NRC Appendix 0212) was not finalized until late ovember 1986.
By that time, the enclosed report was ready to send to 8708050290 s70731 PDR FOIA CORDONB7-377 PDR
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WASHINGTON, D C. 20555 g
DEC s 1986 MEMORANDUM FOR:
Victor Stello, Jr.
Executive Director for Operations FROM:
C. J. Heltemes, Jr., Director
, Office for Analysis and Evaluation l
of Operational Data 1
SUBJECT:
SECTION 208 REPORT TO THE CONGRESS ON ABNORMAL OCCURRENCES FOR APRIL-JUNE 1986 Enclosed for your signature is a Commission paper which forwards the subject draft report to the Commission for approval.
I believe all major issues associated with both the Commission paper and draft report have been resolved.
The Offices of Nuclear Reactor Regulation, Nuclear Material Safety and Safeguards, Nuclear Regulatory Research, Inspection and Enforcement, State Programs, Public Affairs, and Administration (Division of Security), concur.
All Regional Offices concur.
The Office of the General Counsel has no legal l
objections.
There are two items which I would like to bring to your attention in regard to the enclosed draft report.
1.
There was a difference of opinion among the staff as to whether Appendix C, Item 1 (i.e., "Out-of-Sequence Control Rod Withdrawal at Peach Bottom Unit 3") should be reported as an abnormal occurrence (AO). The different perspectives and their resolution are discussed in Attachment A to this memorandum; in summary, Region I now agrees with NRR and AE0D to report the item in Appendix C rather than as an AO.
2.
In the Commission's approval of the first quarter CY 1986 A0 report l
(reference memorandum from John C. Hoyle, Acting Secretary, to you dated September 24,1986), the Commission stated that the iodine-125 brachytherapy source rupture at the University of Cincinnati Medical l
Center (a 1984 event which was the subject of our case study AEOD/C601,
(
issued August 1986) should be considered in the next (i.e., second quarter CY 1986) A0 report.
l The staff position on this issue (i.e., the event is a medical misadmin-
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istration, and therefore is reportable as an A0 under the guidelines i
i delineated in Part II of NRC Appendix 0212) was not finalized until late ovember 1986. By that time, the enclosed report was ready to send to 8708050290 870731 PDR FOIA l
CORDON 87-377 PDR
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the Commission for approval.
Inclusion of that 1984 event in this report would further delay this report by at least two weeks.
Therefore, the staff will include the event as an A0 in the third quarter report, which-is now under preparation. This paragraph is also included in the enclosed Commission paper.
The contact in my office for the enclosures is P. Bobe on 492-4494.
ow swa or c.J.Hemamen A j
q C. J. Heltemes, Jr., Director 1
Office for Analysis and Evaluation
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4 of Operational Data
Enclosures:
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As stated
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Distribution:
PBobe (2) d JCrooks MWilliams FHebdon JHeltemes KBlack SRubin LBettenhausen, RI (AE00 memorandum only)
GHolahan, NRR (AE0D memorandum only)
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- 12/ L/86
) ATE : 11/g/86 0FFICIAL RECORD COPY r
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Attachment A Discussion of Staff Perspectives Regarding the Peach Bottom Out-of-Seouence Control Rod Withdrawal Event Tegion I, who originally proposed the event as an A0, believed it should be reported as an A0 based on (a) personnel errors by four licensed operators were involved, including the shift superintendent and shift supervisor, none of whom recognized that control rod 10-23 had been withdrawn during startup procedures
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rather than rod 02-23; (b) the shift superintendent (who was also the on-site ranager at the time of the event) and shift supervisor bypassed the Rod Sequence j
Control System for control rod 02-23 without assuring that the bypassed control 1
rod was in its correct position; (c) startup continued with rod 02-23 fully inserted instead of fully withdrawn as required; (d) the error remained until it was discovered by the next shift of operators; (e) a similar event occurred during 1977; and (f) the proposed civil penalty for the event was escalated 100 percent because previous corrective actions had not been effective.
Region I also believed that the safety significance of multiple human errors involving a number of licensed operators cannot be adequately assessed by focusing solely on the potential consequences of the specific event in question; such error i
combinations could result in worse consequences under different circumstances.
NRR does not believe that the event meets the criteria for reporting as an A0.
The safety significance of the event was minimal.
They agree that the person-nel errors associated with this event are significant; however, the other personnel errors cited in the writeup as violations since 1983 are of lesser significance. The similar event mentioned by Region I occurred nearly nine years ago; therefore, there is no apparent trend toward events similar to the latest event (i.e., significant personnel errors by licensed operators).
Based on these reasons, NRR believes the event should be reported in Appendix C.
AE00 agrees with NRR's assessment.
In addition, AE0D believes that the event does not meet the intent of the A0 example of "a serious deficiency in rnaragement or procedural controls in major areas." Based on past reporting practice, serious deficiencies generally have to be evident in more than one j
major area (e.g., operating procedures and maintenance procedures, maintenance and training, etc.), or, a very serious widespread breakdown must be evident in management or orocedural controls if only one major area is involved.
Neither of these appear evident in this case; therefore, the event is below the usual threshold for A0 reporting.
However, AEOD agrees the item should be highlighted by including it in the quarterly A0 report under Appendix C.
AE00 discussed the item with NRR and Region I to attain resolution. Region I agreed to an NRR suggestion that the item could be reported in Appendix C and that the differences between the two offices be noted in the AE0D forwarding rnemorandum to the EDO.