ML20246F261

Ofc of Atty General Memo of Investigation Re Seabrook Low Power Testing Transient Event of June 1989

ML20246F261
Person / Time
Site:	Seabrook
Issue date:	08/23/1989
From:	NEW HAMPSHIRE, STATE OF
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References
NUDOCS 8908300241
Download: ML20246F261 (46)

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OFFICE OF THE ATTORNEY GENERAL MEMORANDUM OF INVESTIGATION

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CONCERNING SEABROOK LOW POWER TESTING TRANSIENT LVENT OF JUNE 1989 August 23, 1989 8908300241 890823 FDR ADOCK 05000443 P PDC

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v l TABLE OF CONTENTS-l Page Number I. Summary of Findings . . . . . . . . . . . . . . . . . . . 1 II. Tne Usture and Scope of the Attorney General's Inquiry . . . . . . . . . . . . . . . . . . . . . . . . S A. Contacts with NHY. . . . . . . . . . . . . . . . . 5 B. Contacts with the NRC. . . . . . . . . . . . . . . 7 III. Tne June 22, 1989 Natural Circulation Test Summary of Plant Equipment Parameters . . . . . . . . . 9 IV. Control Room Response During tne Transient Event. . . . 13 -

A. Event Chronology . . . . . . . . . . . . . . . . . 13 B. NHY Actions During the Transient Event . . . . . . 17-

1. Operations staff Actions. . . . . . . . . . . 18

2. Startup Crew Actions. . . . . . . . . . . . . 20 .

3. NHY Management Actions. . . . . . . . . . . . 20 C. Conclusions Regarding the Reasons for NHY Actions During the Transient Event . . . . . . . . 22

1. Inadequate Pre-Test Briefing of the Operations Crew . . . . . . . . . . . . . 22

2. Lack of Clear NHY Policy Concerning Adherence to Test Procedures. . . . . . . . . 24 1

3. Management Unfamiliarity With 2est criteria . 25

4. Cumulative Effect of Number of Individuals Present in the Control Room . . . . . . . . . 26 j i

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A. Chronology of Events After Reactor Trip. . . . . . 29 B. NHY Management and NRC Actions After Reactor Shutcown . . . . . . . . . . . . . . . . . . . . . 32 C. Conc.tusions Concerning NHY Management ana NRC Actions in Response to Reactor Shutdown . . . . . 36 VI. Restructuring of NHY Management . . . . . . . . . . . . 39 i

VII. Recommendations of the Attorney General's Office. . . . 41 I

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SUMMARY

OF FINDINGS l

On' June 22, 1989, a transient event occurred at the Seabrook t

nuclear power facility while low power testing was being conducted i at a 3% power level. Testing was terminated and the reactor shutdown by New Hampshire Yankee (hereafter "NHY") pending an i investigation by the Nuclear Regulatory Commission Region I office (hereafter "NRC"). On June 27, 1989, the Governor requested the OIfice of the Attorney Genera' *o conduct an independent inquiry of the circumstances surrounding the event. The following is a k summary of tne results of our investigation.

At no point during the events of June 22, 1989 was public health or safety at risk. As the NRC report carefully states, the significance of every concern now at issue must be assessed with this point clearly understood. All involved also agree that NHY

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violated testing criteria which required shutdown of the reactor.

Specifically, the conclusions of our inquiry are as follows:

- Communications between the NRC and NHY management led to misunderstandings concerning restart of the reactor and i corrective actions initiated by NHY. On this point, both NHY and the NRC mdst share responsibility;

- Control room operators were inadequately informed j (briefed) of important test limits prior to initiating testing;

- New Hampshire Yankee policy concerning acherence to test procedures was unclear and subject to differing interpretations; NHY management was unfamiliar with test criteria and, therefore, failed to intervene when procedures were violated;

- The number of people in the control room (57) createo an atmosphere that may nave affet ed the decisions of key control room personnel.

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, While not giving rise to safety concerns, the actions of NHY during and after the June 22nd transient event are of serious concern because they are the only inaicator the public now has of the manner in which NHY control room operators and management may respond to unexpected equipment failures in the future. The procedural and management changes instituted by NHY since June 22nd are appropriate and proper, out there is no accurate way to assess the likelihooc of control room operators ignoring operations or test criteria in the future, or of management exercising its judgment so as to comply fully with regulatory requirements at the same time technical solutions to plant problems are being implemented.

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The inquiry by the Attorney General's Office identified four specific factors contributing to the noncompliance with procedures  ;

by NHY employees during the event, and it is our conclusion that l each of these areas (with the exception of the numbers of persons in the control room) is being examined and addressed by NHY. We note, however, that time and an error free exhibition of competence and sensitivity to regulatory and public concerns are prerequisites to the restoration of the trust of New Hampshire's citizens.

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. l In addition to. problems during the test'itself, significant 1

concerns are raised regarding' communications between NHY and the l

NRC during'the initial hours after tne reactor.was shutdown. Our-investigation.inaicated that NHY management made statements to the NRC concerning the event during telepnone conference calls on June-

-22nd and 23rd which failed to adequately convey the actions it was taking and the significance it was attaching to correcting the violations which had occurred. Yet, we have also concluded that NRC' officials failed to adequately articulate their expectations with respect to reactor restart during these conversations so that

'they were clearly understooo by NHY management. As a result, the' NRC became increasingly concerned that NHY was not attaching appropriate significance to the event.

While the consequences of such misunderstandings ultimately come to rest with the licensee which has committea the violation and has the burden to. comply with safety requirements, the responsibility must be shared by the NRC which is tne regulatory agency charged with ensuring that public health and safety are being adequately protected by appropriate actions of the

. licensee. It is the responsibility of the regulator to make explicit its expectations of necessary actions which a licensee must take to restore the necessary measure of public safety, ana to do so immediately after an event has occurred. Otherwise, only

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- the licensee is making that judgment during the initial hours i t1 I

after a transient-event. For these reasons,'it is our conclusion that. steps should-be'taken to ensure more precise communications between NHY and the NRC subsequent to transient events in the future:so that the regulatory expectations of the NRC are understood by NHY, and so that the federal government receives accurate and timely information from NHY.

The text of the report which follows explains the nature and scope of this office's independent inquiry into the circumstances surrounding the June 22, 1989 shutdown of the Seabrook reactor (Part II); a description of the test being conducted and the response of plant equipment to the transient event (Part III); an assessment of NHY's response to the unfolding transient event

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(Part IV); this office's conclusions regarding the response of NHY management and the NRC subsequent to shutdown of the reactor (Part V); the restructuring of NMY management (Part VI); and recommendations are set forth in the. final section (Part VII).

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'II. THE NATURE AND SCOPE OF THE ATTORNEY GENERAL'S INQUIRY On June 27, 1989, the Governor requested this office to initiate an independent inquiry into the circumstances surrounding the events of June 22nd at the'Seabrook nuclear facility. The i report which follows is the result of extensive interviews and briefings by Assistant Attorney General Geoffrey M. Huntington with individuals from New Hampshire Yankee and the Nuclear ,

l Regulatory-Commission Region I office. The New Hampshire pub}ic Utilities Commission greatly Assir P, efforts by proviaing the

. technical expertise of its rs?' .ctadt engineer at the Seabrook Station to accompany e Attorney General's Office in certain briefings in order to acsess the mechanical and technical aspects of'the transient event, and to help translate these parameters into meaningful indices of safety and regulatory Concerns.

A. Contacts with New Hempshire Yankee The New Hampshire Yankee organization was, without qualification, fully cooperative witn our inquiry, and provided the Attorney General's Oftice with access to every incividual and resource requested. At our request, NHY conducted a simulation of the transient event and reactor shutoown at the Seacrook facility's control room simulator so that plant parameters, operator actions and plant equipment response could be observec in the same sequence and timing as occurred on June 22nd.

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• - Interviews were then conducted with 7 NHY employees including'the 3 individuals approached by NRC officials'in the control room during the transient event (Startup Test Director, Startup Test Manager and Assistant. Operations Manager); 3 operations management individuals who were in the control room and/or directly involvea with follow-up actions by NhY including

-telephone conferences with the NRC (Operations Manager, Assistant Station' Manager and Station Manager); and the current Senior Vice Prasi'aent and Chief Operating Officer of NHY. In~adoition, a viceo and audio tape taken of the control room panel display during the event was observed to confirm statements made in individual interviews. Follow-up discussions were held with Mr. 1 i

Feigenbaum. ]l The Unit Shift Supervisor and other control room operations staff were made available by NHY, but were not interviewed by the Attorney General's Office. The uniformity of every factual  ;

account of control room events during the unfolding transient )

l event (both by NHY and the NRC), comoined with the shifting focus of our inquiry from the event itself to actions of NHY in response to the event made interviews of these incividual duplicative and 1

unnecessary.

1 The Attorney General's Office did ask for and received an answer to one question from the Unit Shift Supervisor, but this was not cone in person.

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- B. Contacts ~With the Nuclear Regulatory Commission l'

Because the Attorney General's Office inquiry was initiateo after the NRC had conducted interviews comprising the initial phases of itc own investigation and regulatory enforcement assessment, our~ office aia not proceed via the NRC State Liaison program which provices certain participation rights to states wishing to observe NRC ittspections or investigations. Rather, the Attorney General requested the cooperation of the NRC in deference to the Governor's desire for an independent state inquiry. NRC Region I Administrator William Russell acceded to this-request,.

and established guidelines acceptable ~to this office which protected the independent status of the ongoing NRC process.

Initially, our office received and reviewed certain documents relatea to the scope and nature of the NRC's own investigation, and of observations of NRC inspectors present in the control room on June 22nd. Upon completion of the NRC report detailing the results of that agency's investigation, we visited NRC Regional headquarters on August 5th and 6th to review the report in advance of its release and to discuss its conclusions with members of the investigation team, NRC management, and two or the three inspectors present in the control room on June 22nd.

This ottice agreed that all documents and information provicea by the NRC would remain confidential until such time as the NRC report was released to tne puolic.

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The. cooperation and assistance of Regional. Administrator.

-Russell and his. staff with the Attorney General's investigation.'is greatly appreciated.

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III. THE JUNE 22ND NATURAL CIRCULATION-TEST

SUMMARY

OF PLANT EQUIPMENT PARAMETERS The natural circulation test is one of a series or startup tests required by Nuclear Regulatory Commission regulations. It is conducted at a 3% power level, for the purpose of demonstrating the natural circulation characteristics of a nuclear reactor coolant system. The reactor coolant system is a nuclear component of.the power plant which is used to dissipate and transfer heat produced when a nuclear chain reaction is in progress.

The reactor coolant system is a closed looped system of a water and boron mixture which circulates under pressure. A

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" pressurizer" maintains the pressure of the coolant system.

Guidelines are established requiring tne shutdown of the reactor in the event that the water level in the pressurizer falls below a certain level, or the internal pressure of the coolant system reaches a predetermined level, or the temperature of the sysrem exceeds a specifieo level. During normal operation, reactor coolant pumps maintain a flow due to temperature differential of the coolant system in the reactor. The natural circulation test is designed to demonstrate that, in the event those pumps fail to operate, the reactor coolant system will establish a natural flow due to temperature differential which will continue to dissipate the heat proouced by the cecay heat of the nuclear chain reaction.

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.Trua natural circulation ' test was' initiated on June 22nd when

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the reactor coolant pumps were shut off. As. expected,-after a few l

minutes, the reactor coolant system average temperature began to

' increase and-~show indications of establishing a natural

' circulation _ flow. Approximately 7 minutes'into the test, a l concenser steam dump valve' stuck fully open. This valve is one in a set of 12 wnich are used to control the reactor coolant temperature at times when the main turbine of the Seabrook facility is not using the steam to produce electricity. In other-words, this steam dump valve which stuck open is one in a series

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of valves which are used to aajust (cool) the temperature of the reactor by releasing steam at times when no electricity is being produced but heat is being generated by the reactor.

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Because this valve stuck in the open position and the increased steam flowing through tne open valve could not be supported by the_ low power levels at which the reactor was being operated for the test, tr reactor coolant system temperature began to decrease in a manner unexpected by the test. Wnen temperature aecreases in a pressurized water reactor such as I

Seabrook, the volume of water in the reactor coolant system also i

decreases anu results in a corresponding decrease in pressure in the coolant system pressurizer. As the reactor coolant system coolea, the water level / volume in the pressurizer began to drop ano eventually reached a level whicn violatea a test criteria establi sheo for the purposes of gathering data about the various*

plant systems.

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Tne natural circulation test manual reactor trip criteria called for shutting down the reactor if the mininum water level in the pressurizer reached 17%. -This level was set at 17% for the low' power testing process because levels below that thresholo quite simply do not provide useful cata on the various plant components being tested. There are no safety or operational concerns related to violating this criteria. Inaeed, procedures for full power operation of the SeabrooK Station Call for suutdown of the' reactor only if the water in this pressurizer falls below a 5% level. In the five minutes that the steam aump valve was open, the pressurizer water level reached a mininum of 14.5%.

After the open steam dump valve was discovered and closed, the pressurizer water. level and pressurizer pressure began to rapidly recover. Yet, within five minutes after the valve was closea, the reactor was ordered shutdown anyway because the Unit Shift Supervisor believed that the pressure level in the reactor coolant system was increasing at a rate which would eventually violate a test limit requiring shutdown or the reactor at 2340 psig or an operations limit at 2385 psig. Simply stateo, the Unit Shift Supervisor tripped the reactor, in anticipation or reaching a plant equipment status, one cifferent from the pressurizer water level, which requireo a reactor trip. At the time the reactor was shutdown, the pressurizer water level was at 21%, and pressurizer pressure was at 2310 psig. No technical specifications parameters or safety analysis limits were exceeded other than tne 17%

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k" pressurizer water level' test-criteria.during this transient event. No plant equipment was damaged and no personnel injury occurred. The natural circulation test was introduced into

!- regulation by the NRC arter.the Three Mile Islanc accicent in 1979, and may be conoucted by NHY at a later date when full power testing is completed.

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- t IV. CONTROL-ROOM RESPONSE DURING THE TRANSIENT EVENT A. Event Chronology: June 22nd 10:30 a.m. - 12:45 p.m.

The following is a chronology of the events which.occurrea in the control room on June 22, 1989 during the conduct of the

. natural circulation test until mancal shutdown of the reactor.

The times are approximations aerivea from both the NHY and NRC reports.

Thursday, June 22, 1989 10:30- -- Startup Test Director completes individual briefings of on-shift operations crew members. ,

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All prerequisites to conducting the natural circulation test completed, and Test Director signifies readiness to proceed to the Unit Shift Supervisor (hereafter "USS").

12:19 -- Reactor coolant pumps are manually tripped to initiate the natural circulation test.

12:27 -- Decreasing pressurizer levels first noted ano announcea to the USS.

12:29 -- USS verbally informed Test Director tnat pressurizer level was approaching the 17% test limit (mace a statement concerning "your limit").

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Pressurizer reached the 17% test criteria threshola for manual reactor trip. .USS directed the primary j control board operator to confirm when pressurizer f level reachea 15%, and to state'his ability to stop  !

the aecrease.

12:31 -- Steam Dump Velve was first reported stuck open to the USS, and was immediately closed; pressurizer water level'reachea 14.5%.

12:32 -- NRC Inspector advised NHY Startup Manager of the on-going violation of the 17% test criteria requiring manual trip of the reactor.

12:33 -- Shitt Superintendent informed the USS that Tavg temperature was below 541 F, thus commencing a 15 .

minute time period to restore this parameter to greater than 541 F or manually shutdown the reactor. , i 12:34 -- NRC Inspector approached and informed NHY Startup Test Director of on-going violation of tne 17% test criteria requiring reactor trip. Tne Test Director immediately approached the USS ano informed him of communication from the NRC regarding the trip requirement.

12:34 -- The 14RC Senior Resident Inspector and a NRC Inspector approached and advised NHY Assistant Operations Manager of the on-going violation of the 17% test criteria requiring manual trip of the reactor.

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Manual: reactor trip (shutdown) was directed by the USS with pressurizer level at 21%, but pressurizer pressure at 2310 PSlG -- 30 PSIG 1ess than .he 2340 PSIG level which is also a criteria requiring manual-trip of the reactor.

12:37 -- NHY Assistant Operations Manager informed NHY.

Operations Manager of the test procedure violation, and directea NHY Shift Superintendent to retain the -)

on-shift crew tor debriefing..

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hRC Deputy Regional Administrator informed NHY Vice President of Duclear Production of violation of the manual trip test criteric., and that saic that the ,

violation was "of serious concern" to the NRC.

To fully understand the events of June 22nd, it is essential to understand the organizational chain of command that structured ,

the roles of the NHY individuals in the control room'that day.-

Tests such as the natural circulation test being conductea that aay involve two separate hierarchial lines of authority -- tne operations crew and the startup test crew -- whien have separate chains of commano functioning under the oversight of a celineatea line of authority of NHY management. The operations crew is >

headea by the Unit Shift Supervisor ("USS") and normally consistc of'tne USS ano 2 control room operators responsible for monitoring and operation of specific plant functions and equipment. Because of the nature of the test being conducted on June 22nd, the operations crew consistec of the USS and 4 control board operators.

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P While each licensed operator has authority to shutoown'the reactor, the unit ~ shift supervisor isLresponsible for." maintaining.

a comprehensive perspective cn operating conditions ... Land' is]

L ... tne sole authority.in charge of the control room unless relieved'of that outy [by NHY management].... S e e N H Y .' R e p o r t ,'.

Enclosure'4, p. 2. The startup test crew is headed by.the startup manager, and is comprised of a shift test director, a test airector, and test engineers. See NHY Report, Enclosure 4, p. 3.

o The individuals comprising the startup test organization, wnile not authorized to order the operations crew to snutdown the o

reactor, briefs the' operations crew on the test, oversees the

. conduct of the test, and has authority to terminate the test ano to recommend snutdown of the reactor to the USS or plant management based on improper conduct of the test or plant

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parameters. See'NHY Report, Enclosure 4, p. 3. Simply stated, the startup clew is responsible for the technical preparation and conduct of a test, and the operations crew (headed by the USS) is responsible for implementing the test being conducteo. Id.

In every shirt, both organizations are joined in the chain of command at the shift superintendent posi*. ion which is the first tier of the NHY management structure. Above that position are the assistant operations manager, operations manager, assistant station manager, the station manager, anc the vice president of nuclear production -- except for the VP-NP, each of these individuals has authority to rollow procedures to interceae ana

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overrule the operations decision of the USS or shift

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hierar'chial structure. outlined above,'only tne assistant station manager.was not present in tne control room during the transient event on June 22, 1989.

B. NHY Actions During the Transient Event Of individuals in the control room with the authority and responsibility to intervene and order or recommend that the test De terminated and the reactor trippea, not one NHY operations staff, startup test staff, or NHY management official-acted to comply with the natural. circulation test criteria requiring a manual trip of the reactor when the pressurizer level dropped

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below.17%. There is no disagreement on this point. There existed a 6 minute time interval in which only NRC inspectors observing the test and indicators of the operating status of plant equipment recognizec and acted to seek compliance with the test procedures which had been delineated in advance.

Generally, NHY control room staff were focusing on operating the plant anc compensating for transient conditions causeo by tne failea steam valve, and in this light viewed the trip criteria as guidance ratner than manoatory. The startup crew recognizeo the violation ror what it was, but were tentative in their assessment, and failea to intervene in the operations enain of con.na nd to 4 l

l terminate the test and recommend a reactor trip. Representatives

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of NHY management, on the otner hand,_ tail'ed to exercise their-authority to act because these individuals generally lacked a basic comprehension of the test criteria, and tnus were unaware a B violation of test procedures was even occurring.

1. Operations Staff Actions our inquiry into the performance of the operations crew revealed a surprisingly uniform assessment of why a test criteria was violated by_the unit shift supervisor and the control room operators -- tne operations crew, ano the USS specifically, did not view the test requirement calling for manual trip of the reactor below a pressurizer level of 174 as a mandatory proceaure. Rather, it was understood by tue operations crew to be" a guiceline tor termination of the natural circulation test. A

, guideline that, if violatea, signaleo the end of useful cata collection but presented no safety or operational concern when attempting to compensate tor transient conoitions such as occurred on June 22nd.

The USS was quite aware of the 17% trip criteria, and tnat it hao been breached. As the pressurizer level fell below tne 17%

. level, he directed the relevent control board opeator to monitor it and call out the declining levels, and ne tnen informed the startup test director that: "your limit" has been exceeded.

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By'a111 accounts, the USS-viewed the unfolding transient.

. plant. conditions:from an operationali perspective, with a mind ,

focused on compensating for the heat loss being caused by a stuck 1 valve and-towara regaining specific operating parameters. 'It was

not until other plant parameters were not recovering.in an

acceptable manner to the USS that he'ordereo.the reactor trippea.

well in advance of violating any operating licensing or safety criteria.

But for the violation of the test criteria, the NRC has >

determined that the operations crew appropriately responded to the valve.railure and tne resulting transient event. See NRC Report,

p. 6. We.see'no basis to question this conclusion. The videotape' of the event' indicates' no confusion, no disagreement, and.no.

hesitation as control room decisions were~made.

It corroborates all indiviaual accounts that the USS exercised unquestioned authority in a manner designated to correct operational transients within normal operating parameters, but in clear violation of test .

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parameters which he was aware which he thought aid not apply.2 It also confirms that no other control room operator acteo to contradict others, the U.S.S., and comply with the test criteria.  !

2 Recall, bt is the pressurizer water level criteria set for^ reactor shutcown in the operating license for the Seabrook L facility.

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< 2. Startup Crew Actions Interviews of the startup test director and test manager indicate a clear understanding that the test criteria was not simply'guicance, but that: it required a reactor trip'on June

.22nd. Both individuals, however, tailea to assert their authority to terminate that test and to recommend to the USS that the reactor be trippeo.

While the test airector informea the USS of the NRC's

" concern" after being approached by the NRC inspector, he aeferrea to the USS's response that it would be taken care of. Tne startup manager statea to this office that he did not respond to the violation of the 17% criteria ana questioning by the NRC because he was attempting to assess if there were any overricing reasons

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why the USS was failing to trip the reactor. It remains unclear at what point either individual would have asserted his authority to challenge the actions of the USS.

3. NHY Management Actions The NHY management team was well represented in the control  ;

room on June 22nd. The shift superintendent, assistant operations manager, operations manager, station manager and vice presioent of nuclear production were all in the control room for the entire trarsient event.3 Unile each of tnese individuals, with the exception or the VP-NP, had supervisory responsibilities in the 3 The assistant station manager ooservea initiation of the test, but left the control room prior to the onset of equipment complications.

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, commanu'neirarchy allowing them to order a manual reactor trip

'wnen the.USS failea to do so,.our interviews indicated that not

^ one possessed independent. knowledge or the 17% trip criteria so-tnat'he uncerstood that plant conditions called for a manual trip of-the reactor. Of this group, only the' assistant operations manager'(AOM) knew of tne breach of the test criteria Defore the reactor was shutdown, and he was told.by the NRC. After he was approachea by the NRC, the AOM asked the test airector if it was true'that a test criteria hac been exceedea, and was tolo'tnat the USS knew and would take care of it. Our interviews inoicate that betore the AOM coula act on this confirmation, the USS had orderea the reactor shutdown. The AOM then immediately informed.the operations manager of the violation.4

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4 Perhaps reflective of the intensity of events and short durati'on of the transient, our interviews reveal a difference between the recollections of the NRC observers on this point ano those of NHY individuals present in the control room. NRC docun.ents and our interviews with HRC of ticials indicate that, immediately after speaking with tne test director, the AOM spoke to the operations manager and the USS prior to the USS shutting down tne reactor. Infact, NRC observers noted that: " Subsequently

[after the communication between the AOM, operations manager, ano USS), and without a clear impression of whether the response was or was not prompted by the expression of NRC concern, ... tne USS cirected a control room operator to trip the reactor." See NRC Observations Regarding Seabrook Natural Circulation Test, p. 3.

Interviews of NHY individuals reflect vivia recollections that no interaction occurred between the AOM anc the Operations Manager ano the USS prior to the reactor trip, and that the trip occurred within seconos of the AOM's confirmation of test criteria with the Test Director. While these differences have little significance, they serve as a reminder that the duration of the transient event was less than 6 minutes, ano both human performance and recollection are less than uniformly reliable.

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-While each management representative uncerstood the nature of.the transient conditions which the control room operators were responding to, they were uninformed.With respect to the specific test criteria calling for a reactor shutdown at 17% pressurizer L level. Tnus, management focused on plant recovery and operational 1

limitations, and offerea no supervisory role with respect to 1

testing procecures. They were not prepared to address specifics l of the natural circulation test being conoucteo, even though it tell within their oversight responsibilities.

C. -Conclusions Regarding the Reasons for NHY Actions During the Event l 1. Inacequate Pre-test Briefing of the Operations Crew .

l l A fundamental responsibility of the startup test organization is to'acequately brief all members o.t the operaticns ,

crew on the criteria of tne test which will be conducted during

.their snitt. This dio not occur prior to tne June 22nd natural circulation test.

I In this instance, the control room operators had conducted a practice test in the control room simulator at Seabrook Station in May, 1986, ano in a course form late in 1983, but were never again briefeo as a crew. Twenty-four hours before the test, the startup test organization provideo each operations crew member with a copy of the test anc reactor trip requirements. 'ihe morning 01 June 22no as they preparea to initiate operations, each operator ano L

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the USS was individually briefed by'the test director on various

-facets of the test, including the 17% reactor; trip criteria.

While'procecurec'aic not' require _ preparation of the crew as.a group, all parties involvec agree that what was done was in' effective, ano this office concurrs with that conclusion.

The natural circula. tion test was the most complex low power test to be conouctea prict to-full power operation. It also callea for operation of the reactor at the highest power levels to

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date, ano. involved a greater number or control room operators than is ordinarily necessary to run the reactor (5 instead of 3).

These factors, combined with the amount of time which hac passea since instruction hac been provided to the operators, demandec

that a concentrated briefing be providea by the startup crew. On

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this point, both the NRC and NHY evaluations concur with our tindings. See NHY Report, Response Letter p. 2; NRC Report, p. 21.

In response to identifying inacequate pretest briefing proceuures as a contributing factor to the June 22nd transient event, NHY has initiated revisions to the Startup Test program to require more comprehensive pre-test briefings, ano aaditional preparation (including simulator rehersals) of operations crews before they assume shift duties. See NHY Report, Enclosure 1, p.

3. she Office of the Attorney General concurs with tnis remedy, ano agrees that it acuresses the noted aeficiency.

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• 2. Lack of Clear NHY Directives Concerning Adherance to

,I Test Procedures The lack'of explicit directives of the procedure compliance policy in the existing Seabrook Station Mar.agement Manual is I l anotner contributing cause of the Operations crew's failure to auhere to tne reactor trip criteria of'the natural circulation test. Failure of the USS to adhere to the test criteria is explained succinct)y by-his audible' comment to the test cirector uuring the unfolding cransient event. As plant conditions breached the 17% criteria, he calleo out to the test airector that "your limit" was just passco. The operations crew did not view the criteria as a binaing operational limit of the same status as a license limit or a limit based on technical speciriciations. As .

such, the 17% test limit became guidance and was relegated to a secondary concern when the operational transient occurred and the .

USS began to work toward recovering from the heat loss causec by the stuck valve.

Both the NRC and NHY investigations focused extensively on tnis aspect of the June 22nd event, and aetermined that lack of clear policy indeec contributed to the procedurel violations. NHY Report, Enclosure 4, p. 10, and Enclosure 4, Appencix p. 17; NRC Report, pp. 20-21. We reach the same conclusion, noting that the instructions set forth in the Operations Management Manual incluaeo tne following:

, , Plant operation should be conducted in accoraance with, applicable procedures. If procedures are deficient, a procedure change shoulo be initiated.

An exception to this policy is that in emergency conditions operators may take whatever action is r necessary to place the plant in a. safe conoition, ana to protect equipment, personnel and public safety without first initiating.a procedure change.

[ Emphasis added.]

,See NHY Report Enclosure 4, p. 7. Within hours of the June 22nd event, NHY identified the deficiency of this anc other compliance procedures, ano implemented changes. Tnese and subsequent procedural amenoments specity that departure from approved procecures is permissible only when suen action is requirea to ,

protect the public healtn and safety, personnel safety, or to prevent serious damage to plant equipment. See NHY Report .

Enclosure 1, p. 1; Enclosure 4, Appencix p. 17-18. Our inquiry inaicates that the review and amendments aadressing procecural ,

compliance directives which guide operations staff during transient plant conditions are well directed,

3. Management Unfamiliarity With Test Criteria.

The lack of awareness or the natural circulation test  !

criteria by members of NHY management in the control room was a breach of responsibility by those who are charged with being most responsible. While these individuals clearly understooo the test and the status of critical plant functions curing the unfolding transient, our inquiry indicated that not one possessed the requisite knowleuge to step into the transient event to airect adnerence with the test criteria oy ordering a reactor snutcown

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Tne command hierarchy was established to ensure that' operational woula De mace consistent with NHY procecures, and tne protection of public healtn i.nd safety requires informea management personnel asserting their authority when the control room operations staft is in error. Wnile public health ano sarety were not at risk on June 22nd, steps should be taken to assure that every individual in the chain of commana who is present in the control room is substantively brietea so that he is capable of executing his responsibilities. Policy amendments planned by NHY appear to address one aspect of this concern -- that operations management define their re:3 possibilities upon entering the horsesnoe area of the control room -- but do not focus on

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instituting procedures aimed at assuring a greater understanding of critical test criteria by this group of individuals. See NHY

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Report, Enclosure 1, p. 4. It is our conclusion that further assurances are necessary in this regara.

4. Cumulative Effect of the Number of Individuals q Present in the Control Room Present in the control room on June 22na were fifty-seven (S7) people either participating or observing the test and transient event. This number was without precedent in the 2 1/2 year history of control room activities, and it is our conclusion that it may have been a factor contributing to the operations ano startup crews' failure to manually shutaown the reactor.

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q Bys agreeraent, conduct of'the natural' circulation test was to be_a training exercise for all of the.different operations crews and other NHY staff. Accordingly, tha test was conductea at a time allowing for as many observers as possiole to attend. The complexity or the test, and the fact that it involved operdting the reactor at the highest power levels to date also drew a r.

significant number of NHY management personnel. In any event, the individuals called upon by the test criteria to terminate the test' and seek a manual reactor trip were making decisions in an unusual  !

control room atmosphere.

While there exists no indication that the control room

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suffereo from noise or confusion which interfered with the execution of the test, our interviews suggest that an unspoken

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momentum to complete the test successfully may have affected the performance of tne startup and operations crews. This is not uniformly acknowledged amo'ig NHY management and staff level incitiduals. Yet, our int erviews indicated a feeling (alueit aided by hinasight) that :he onshift startup ano operations crews were "on show" witn an "aaoed burden" to meet the " inherent goal to have a successful startup program." There are no indications of any overt pressure by NHY management to conduct a successful test, but the pervacing team spirit, combined with tne presence of so many peers and manager ent, may have impacted the decision making process of these individuals by instilling a reluctance to taxe any action out of orainary.

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Neither the-NRC nor NHY have noted the number of control toom observers as a factor affecting the performance of control room statf, and from a regulatory perspective it may in fact be correct to expect satisfactory performance by on-shift stafr regardless'of who is present in the control room. Yet tne

. consistency ana conviction with which this atmcsphere was conveyed

.to the Attorney General's Office indicates that it may have.been a factor contributing to the events of June 22na.

The NHY Corrective Action Plan proposes to revise the current access policy to establish a maximum number of personnel allowea in the control room. It is our conclusion that such a change is warrantea, along with a taoughtful review of other procedures whicn may be implemented to retain a consistent working

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environment for on-shift staff and to avoid a fishbowl type of control room atmosphere during future operations tests.

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V. RESPONSE OF NHY MANAGEMENT AND THE NRC AFTER REACTOR SHUTDCWN I

A. Chronology of Events Arter Reactor Trip l,-

Thursday, June 22, 1989 12:36 p.m. --

Manual trip of the reactor.

12:45 p.m. -- Meeting in NHY Station Manager's office to discuss the test criteria violation ano subsequent reactor trip. Event Evaluation Team was initiated.

1:00 p.m. -- Management / Supervision meeting convened'by Vice President of Nuclear Production (hereafter "VP-NP") to discuss test criteria violation and -

subsequent reactor trip. Discusseo:

- Cause

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- Sequence or Events

- Confirmation of 17% procecural violation

- Determine necessary action to be taken prior to restart 1:30 p.m. -- Private meeting between VP-NP and Station Manager concerning appropriate management response.

2:45 p.m. -- NHY Station Manager commits to NRC Senior Resident Inspector that plant restart will not occur without advance NRC concurrence.

2:10 p.m. --

VP-NP confirms that botn the Event Evaluation Team and Incepenaent Selt Evaluation Teams haa been initiateo.

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to 4: 20 p.m. --

NHY " Post Trip. Review" Meeting. Attended by L approximately 23' individuals including relevant j control room operations. staff.

Subject:

Assess plant equipment ~ response and current. status, q Purposefully delayed debriefing of operations staff on procedural violations. See NHY Report,  ;

L Enclosure 4, Appendix p. 7.

4:30 p.m. --

NHY VP-NP convenec a management meeting to prepare for scheauled 6:00 p.m. telephone conterence call with NRC Projects Branch Chief.

5:00 p.m. -- " Post Trip Review" report completeo With initial -  ;

information anc conclusions concerning the test procedure violations and plant' response .

parameters.

6:00 p.m. -- Conference call between NHY management and NRC . , .

Projects Branch Chief to discuss the reactor transient event, procedural noncompliance, as well as subsequent, on-going and planned NHY corrective actions. Second telephone conference call scheduled for 7:30 a.m. Friday. See NHY Report, Enclosure 4, Appendix p. 9-12.

9:00 p.m. -- VP-NP adjourneo internal discussions which nad concluaed that:

(1) The natural circulation test i

J criteria was not improper, and a 17% pressurizer 1evel was an appropriate reactor trip that shoulo remain in place.

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U (2) The USS was in error for not oraering.a' reactor trip at the 17% pressurizer level.

I. r (3) The need for stronger NHY policy and direction regarding proceaural aoherence during plant transient conditions was agreeo upon and all present were askea to consider the discussed options in preparation for the next day's conference call with thC NRC.

See NHY Report, Enclosure 4, Appenaix p. 14.

11: 15 p.m. --

The VP-NP brieted NHY President ana CEO witn a summary of the 6:00 p.m. conference call witn tne.

NRC.

Fricay, June 23, 1989 6:45 a.m. -- Pre-conference call meeting of NHY management.

7:30 a.m. --

Telephone conference call between NHY management and NRC Projects Branch Chief to discuss recommended procedural changes, plant equipment status and planned NHY corrective actions, 11:40 a.m. -- NHY/NRC onsite inspectors meeting prior to inspectors leaving the facility.

1:50 p.m. --

NRC Deputy Regional Administrator phone conversation with NHY Presicent and CEO informing NHY that an NRC inspection team was being f ornied to investigate tne transient event and subsequent management response.

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B'. NHY Management and NRC Actions After Reactor Snutdown 1.

1 NHY management's response subsequent to the event itself nas been tne subject or significant discussion in the NHY ana NRC reports. ihe NRC report citea hHY management response on Thursday arter the reactor shutdown as "satety significant." See NRC Report, p. 29. Consistent witn this, the NHY organization reacted to the event by relieving the Vice President of Nuclear Production (VP-NP)'from all responsibilities, and publicly stating that management response to the shutdown was." inappropriate" and did not " reflect NHY policy"; and that " unauthorized" statements were mace to the NRC concerning restart. See NHY Press Release; July 13, 1989.

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The telephone conterence calls between NHY management representatives and the NRC at 6:00 p.m. Thursday and 7: 30 a.m.

Friday are at the center of such conclusions. Precisely what transpireo during those two phone conference calls can not be re-created, but it is clear from our interviews that the message NHY thought it was conveying on Thursday, June 22nd was not hearc by the NRC, ano the significance of the NRC's responses was not understood by NHY management. As a result, members of NHY participating in these calls felt that their efforts were what the NRC wanted to see in response to the incident, and the NRC concluced that NHY management was minimizing the event ano prematurely pusning to testart the reactor.

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. Our interviews.with inaivianals of NHY management who were present curing the Thursaay 6:00 p.m. conference call. reveal a near uniform assessment of what took pltce -- that'the VP-NP began by briefing the NRC on the plant status during.the transient event, and the' partial results of NHY's preliminary review which had been initiated' earlier in the afternoon; that NHY oia not have concise, direct answers to provide.in response to some questions askeo by the NRC. representative, but that the issues raiseo were addressed without making excuses for improper conauct; ana that NHY haa agreed not to restart the reactor over 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> earlier, so that talk-about recoiness to restart was spoken with that restriction uncerstood anc it was therefore proper to continue with preparations . sa; d such a goal . While several of tnese same individuals recognized that the NRC representative was quite

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concernea about the procecural violations and associated issues, no one interviewed icentified that the NRC was also concerned about NHY's preparations toward restart simultaneously with its evaluation of the event. To NHY management, it was a given that no restart would occur until an assessment was conoucted which satisried the NRC.

Such impressions of NHY management personnel became even stronger curing the Fricay morning telepnone conterence call with the URL. <egy NFY official interviewed who was present during both calls felt quite secure at tne conclusion of Fricay's phone conversation that the NRC concurred with the steps being taken,

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ano that theRNRC representative neeoed only to speak with NRC management about setting a. target time for plant restart in parallel with the measures being taken to address the' procedural violations. It was'not until later that morning when NRC inspectors were. leaving the tacility, and at 1:50 p.m. when the NRC Deputy Regional Administrator phoned NHY President and CEO Eaward Brown, that these management personnel graspeu the true extent of the NRC's regulatory concerns.

Our interviews indicate NHY officials hung up from the Thursday evening telephone conference call feeling that serious issues. remained but that they were neaced in the right direction.

However, the NRC Region I representative with whom they had spoken hac growing concerns about what he perceived to be the casual

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manner in which plant officials seemed to be viewing the procedural violations. The NRC report states:

The initial management thrust following this event appeared to be to resolve any equipment problems necessary to resume testing. An in-depth review of the cause or causes leading to the improper conouct of the ... test apparently did not take place prior to an initial management cecision to resume l testing. See NRC Report, p. 28.

Not expressly statea in the report, but clearly asserted by Region I otficials in our discussions, was the impression on Thursaay that NHY was rationalizing its performance rather than taking affirmative steps to implement corrective actions prior to restarting tne i i

reactor.

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. References to restart of the reactor we're also viewea as  !

improper given NHY management's preliminary assessment of the reasons for the failure to adhere to test procedures,-the appropriateness of the 17% level as a manual trip criteria, ano the policy concerns raisea by the railure of' three NHY inciviauals to respond to prompting oy NRC observers in the control room.

Indeed, our interviews indicatea that NRC-otticials were dismayec-that NHY appeared Thurscay evening to be even considering reactor restart on Fricay. Tnat NHY had already agreed not to restart the reactor'without hRC concurrence may have changed NHY'S view aoout the legitimacy of working toward restart as a management goal, but it clearly dio not alter the NRC's. Unfortunately, NHY management I

aid not perceive this, and NRC ofticials thought their concern was i

so abundantly clear that it did not need to be more explicitly {

statea.

I When the Friday morning conference call was initiated at 7:30 a.m., NHY had concrete answers ano solutions to many of NRC's key concerns which had been addressed only preliminarily the prtor evening. Yet, our inquiry revealea tnat the rocus or the NRC's concerns had now changed from the previous day. By Fricoy , the important issue to the NRC were not what procedural tixes were necessary prior to restart, but why NHY wantea (on Tnursday) to restart witnoyt attachina significant importance to those procedural violatiopr ano fixing them before moving forwara.

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Thus, the. impression of several NHY individuals participating in s

the Friday morning call was that the NRC.was satisfied with the steps.taken. But'that~ impression would-last only until eat _y that afternoon when the Deputy Regional Administrator for NRC. Region I woala phone the NHY Presiaent and'CEO to inform him that a Confirmatory Action Letter was being issuea ano tnat an NRC investigation was about-to commence.

C. Conclusions Concerning NHY Management and NRC Actions In Response to1 Reactor Shutoown There can be no argument that NHY management bore full ,

responsibility for addressing every concern of NRC officials before restarting the Seabrook reactor. To restart the reactor .

without attirmatively assessing the appropriateness of the trip criteria and the procedures governing the actions of control room ,.

operators would have been unreasonable. We ao not believe, however, that this was the intent of NHY management on Thursday, June 22na, even though the impression was conveyed to the NRC that NHi wished to restart without such an assessment.

2 A Confirmatory Action Letter (" CAL") is a letter memorializing an oral agreement between the NRC ana a utility licensee regaraing specific commitments made uy the licensee to uncertake corrective actions, and regaraing the operating status of the plant. In this instance, tne June 23, 1969 CAL confirmed an agreement by NHi not to restart the reactor prior to a full evaluation or the transient event ana management actions tnereafter. The i4RC nas not oraered continued shutdown or the Seaorook facility, and NHY is not prohibitea by federal law from conaucting furtaer low power operations at any time. Rather, low power testing nas ceased by agreement between the two entities.

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It is or serious concern that both NHY and the NRC failed to acequately communicate and understand each other's positions witn respect to necessary corrective' actions, regulatory expectations, and affirmative steps already taken on Thursday toward resolving the cause of the violations. It is our conclusion that this

. failure'was sharea by both entities.

NHY management clearly was not sensitive to the regulatory expectations of the DRC. The Vice President of Nuclear Procuction was twice tolo by NRC management officials that the startup and operations crews' failure to follow proceoures was of " significant concern" to the agency, and all interviews indicated that the NRC's displeasure was apparent during the Thursaay phone conterence.

NRC officials, however, reached conclusions concerning the actions (or lack of actions) by NHY to address the procedural noncompliance without closely identifying tne accuracy of those impressions. The NRC report concluces, our discussions With NRC officials indicate that it was not until after a Friday atternoon phone call from the Deputy Regional Administrator initiating the NRC enforcement process, that NHY assigned its Independent Event Evaluation 'Aeam to assess the company's performance ot necessary corrective actions. See NRC Report, p. 28. Yet, NHY had in fact formally activated its Independent Event Evaluation Team at approxin.a tely 12 : 4 5 p.m. Thursday, June 22nc -- a fact unnnown to the hkC until our own interviews in August. See NHY Report, Enclosure 4, Appenuix p. 4.

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'While these misperceptions involvec no public health and safety consequences in this instance, 'the citizens of New t

' Hampshire rely on both NHY and the NRC to respona to unexpectea circumstances at the Seaurook facility in a manner wnicn leaves no doubt as to what has happened, what is.being done, and what must be aadressed to complete a response that ensures the safety or the

.public and proper operation of the plant. Yes,.tne NRC stated it was " concerned" about procedural noncompliance, out it apparently never expressed an identifiable stanuard or expectation by wnich NHY knew it would be.juoged as a licensee. Likewise,'IU12 management failed to identify clearly the steps being taken oy the utility in response to the situation, and to isolate the exact prerequisites to rectart of the reactor in light of its earlier agreement not to do so.

-Neither the NHY nor the NRC reports attach significance to this. failure to adequately communicate which was observed so clearly in our interviews. Steps should be implemented by both NHY and the hRC, however, to adaress this problem.

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.- l VI. RESTRUCTURING OF NHY MANAGEMENT On July 13, 1989, the NHY President anc CEO issuea a press statement announcing a planned realignment of NHY management and the resignation of the NHY Vice President of Nuclear Production.

The stateo reason for relieving the VP-NP of'his outies at Seabrook Station was tnat unauthorized and inappropriate statements were taade to the NRC on June 22nd concerning restart of tne Seabrook reactor. See NHY Report, Enclosure 1, p. 6.

The Attorney General's Office draws no conclusions concerning actions by the NHY organization relieving the VP-NP from all responsibilities. The sole issue considered by this Office is whether the VP-NP was autnorized to represent NHY in discussions with the NRC in the initial hours after the June 22nd event, ana whether the authority ot nanagement positions restructure by NHY is consistent with current operations procedures of the organization.

In his July 13th statement to the press the Presioent and CEO incicated that statements made to the NRC by the VP-NP concerning reactor restart were made without the Presiaent's

" knowledge, concurrence or authorization," and that they were

" unauthorized ano inappropriate." See NHY Press Release, July 13, 1989. Yet, Our interviews, uniformly indicate that Mr. Thomas mace no statements to tne NRC on June 22na or 23rc in tne presence

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.of other NHY individuals which they observed to be beyond his authority to make as the Vice President of Nuclear Production given applicable operations management procedures in place at that time.

NHY policy did not require tne "knowleoge, concurrence or authorization" of the NHY President and CEO prior to restarting the reactor (or setting a target time to do so) after a transient event such as occurred on June 22, 1989; and such a policy requirement is not clearly present today. The precise authority of specific positions in the NHY management structure shoulo be clarifico in this respect so that current NHY staff and management, the NRC, anc the State of New Hampshire have a clear unoerstanaing regarding this issue.

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VII. RECOMMENDATIONS FOR FUTURE STATE ACTIONS

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The NHY Corrective Action Plan aadresses nearly all of the necessary procodural changes arising out of tne events of June 22no~. See NHY Report, Enclosure 1. The State should monitor the company's implementation of these corrective actions, and the Attorney General's Office will seek a response from NHY on the issues we raise in this report.

In aaoition, the State of New Hampshire may benefit from the lessons of this incident by considering actions of its own.

Specifically, four steps should be considered to further New Hampshire's involvement and understanding of future events which may occur at the Seabrock Station.

1. The Governor shoula appoint a State Liaison Officer to act as the Governor's primary representative for communications with the Nuclear Regulatory Commission, and to participate in the Liaison Program offered by the NRC to states with fixed nuclear facilities. The former Director of the Office of Emergency Management served as New Hampshire's liaison officer prior to his resignation this month. The Governor should consider wnich state representatives may best serve in this capacity as the Governor's personal liaison witn the NFC for all issues relating to Seabrook's operation and the NRC's regulation of it, f

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2. The State of New Hampshire shoula enter into an f I

agreement with the NRC, via the State Liaison Program, wnich will l provide the State Liaison Officer, or his/her designate, with access to future NRC inspections end investigations of the i

Seabrook facility. Such an agreement between New Hampsnire ano the NRC woulo assure that opportunities to accompany the federal government in its conduct of activities at Seabrook are not missed, j

3. The State of New Hampshire shoula enter into an agreement with New Hampshire Yankee Organization to provide tne State Liaison Ofticer and other state officials with accecs to the Seabrook facility and to NHY employees for purposes of gathering information and establishing open communications regarding plant operations, equipment status, ano planned tests of reactor parameters. Such a cooperative agreement between the State and NHY would enhance New Hampshire's knowledge and confidence in the operational safeguarde exercised by plant officials.

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, 4. The State shoulo consider changes to enhance New Hampsnire's ability to monitor actions of botn FHY and the NRC.

Currently, the Governor's Office, Office of Emergency Management, Public Utilities Commission e Department of Public Health Services,

. Attorney General's Oftice, ano the Nuclear Waste Policy Aavisory Committee each undertake to monitor ana respond to actions by NHY ano the NRC. Consolidation of the State's efforts to monitor amenoments to federal laws, and NRC rule changes and cecisions, as well as specitic actions being uncertaken by NHY should oe trackea for the specific purpose of developing a coordinated response on behalf of the Governor. Specifically, it may be appropriate to consider amenoments to RSA 12 5- G: 4 so that either the existing Nuclear Waste Policy Advisory Committee, or a new oversight committee of agency representatives with specific expertise coula be utilizeo to track and coorainate the State's response to these issues wnich cross the jurisdictional lines of the various state departments out have public health and safety implications to New i

Hampshire's citizens.

The Attorney General's Office stands reacy to assist in the l

Implementation of any one, or all, of the foregoing recommendations.

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