ML20246F965
| ML20246F965 | |
| Person / Time | |
|---|---|
| Site: | Seabrook  |
| Issue date: | 08/28/1989 |
| From: | Shannon J MASSACHUSETTS, COMMONWEALTH OF |
| To: | Atomic Safety and Licensing Board Panel |
| Shared Package | |
| ML20246F967 | List: |
| References | |
| CON-#389-9106 OL, NUDOCS 8908310185 | |
| Download: ML20246F965 (142) | |
Text
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t; UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION 89 M5 29 P4 :17 ATOMIC SAFETY AND LICENSING BOARD
(~
Befor'e Administrative Judges:
hs[ i,:,
t V: %-
Ivan W. Smith, Chairman Dr. Richard F. Cole Dr. Kenneth A. McCollom
)
In the Matter of
)
)
PUBLIC SERVICE COMPANY OF
)
Docket Nos. 50-443-OL NEW HAMPSHIRE, et al.
)
50-444-OL
)
(Seabrook Station,
)
Units 1 and 2)
)
August 28, 1989
)
INTERVENERS' MOTION FOR LEAVE TO ADD BASES TO LOW POWER TESTING CONTENTION FILED ON JULY 21, 1989 AND TO ADMIT FURTHER CONTENTIONS ARISING FROM LOW FOWER TESTING EVENTS OR, IN THE ALTERNATIVE, TO REOPEN THE RECORD AND SECOND REQUEST FOR HEARING INTRODUCTION On July 21, 1989, the Massachusetts Attorney General
(" Mass AG"), Seacost Anti-Pollution League ("SAPL") and the New England Coalition on Nuclear Pollution ("NECNP") (collectively, the " Interveners") filed a motion seeking to have this Board admit a contention arising from low power testing events at Seabrock on June 22 and 23, 1989.
(" July Contention" or l
1 p
ADO OO j3 G
hk_~
(
%C l
- alternatively:"JI-LP-1").
As expected, further-f 4
information has now become available to Interveners A# and as N'
predicted'in their' July Contention at 13 n.8, Interveners now seek to augment the~ July Contention with additional factual e
a'nd technical bases and in addition to file further contentions.
tr As_notedLin the Mass AG*s May 31s 1989 Motion to Hold Open the Record Pending. Low Power Testing at 8-9, in the Mass AG's T
June 21, 1989 Reply to Applicants and Staff Responses to the May 31 motion at 2-3, n. 2 and 3 and in the Interveners' July 21 Motion at 12-13.n.8, Interveners in the absence of any control" exerted over low power testing litigation by this Board
- must continually make a Hobson's choice with regard-to the timing of the' filing of any low power contention.
On the one 1/- On August-7, 1989 the Applicants filed their " Answer" to JI-LP-1.
On August 18, the staff filed its " Response" to this
+
contention which was received by-the Mass AG on August 22, 1988.
Attached to the Staff Response was Staff Inspection Report 50-443/89-82.
(Attachment 5 to' Staff Response, NRC Augmented Inspection Team Report ("AIT")).
The Mass-AG has a right to file a reply to the Staff's and Applicants' responses to the July Contention for the following reasons: 1)
Interveners have a right to reply to responses to contentions;
- 2) Applicants raised a particular defense for the first time in response' cf.
Applicants' August 7 Answer at 28 n.
68; and 3) the Staff has argued, inter alia, that the " fundamental flaw" pleading requirement developed in the context of emergency planning be applied to the July Contention.
As to this last
. claim, not only does the Mass AG claim a right to reply to this new argument, but in the event that this Board were to adopt such a pleading requirement the Interveners would be entitled to conform their low power testing pleadings to such a requirement. 'The Mass AG has sought without success to have this Board set:a date for the filing of a reply to the Staff's and Applicants
- responses.
In the absence of any guidelines, the Mass AG will file a reply to both responses on or about September 1, 1989 accompanied by a motion for leave to file e
such a reply.
(The Mass AG notes that the Staff response was L
received on August 22 and that it was mailed regular mail on August 18, 1989.)
2/
Specifically, the AIT received with the Staff Response on August 22, 1989. _ _ _ _ _ _ _ _ _
i
hand, because an admissible contention must have adequate basis and specificity to be admitted interveners must have sufficient information at hand before they can draft an adequate contention.
On the other hand, in the absence of anY guidelines in terms of the number of weeks, days or (apparently in the Staff's benighted view) hours after sufficient information is available a contention should be filed, Interveners are hesitant to wait even an afternoon before filing their contentions once additional information sufficient to support their contention is available, as it now is after August 22, 1989.
Moreover, as the Mass AG argued in his May 31 motion, low power testing and'the June 22-23 events are material to the issuance of a full power license and thus under UCS v.
NRC, 735 F.2d 1437 (D.C. Ci r. 1984), this Board may not apply the motion to reopen standard to contentions filed in response to low-power testing events.A#
This Board to date has not addressed this issue.
Tr. 28287.
As predicted in Mass AG's June 21 Reply at 2-3, an important procedural consequence has resulted from this Board's decision not to resolve this important threshold 3/
As should now be familiar to this Board (May 31 Motion at 9-10, June 21 Reply at 3 n.2 and 3 and July 21 Motion at 12 n.7), the Interveners do not believe that the late-filed contention standard should be applicable but ALAB-918 clearly governs this issue and interveners therefore assume that any contention they now file must meet the standards of 10 CFR
$2.714(a)(1).
Of course, Interveners must be given additional time after receipt of sufficient information to meet the additional filing burden of $2.714(a).
put another way:
in determining " good cause" credit should be given for the time necessary for example to locate and identify prospective expert witnesses and to summarize their testimony.
See ALAB - 918, 29 NRC slip op. at 18-20 (June 20, 1989).
As obvious and inescapable as this proposition appears to be, the Interveners are certain that if they wait another day (or hour) they risk this Board finding undue delay in submitting these additional bases and contentions after the August 22 receipt of the AIT. l L
o
issue:
Interveners' rights to litigate the low power testing events have been effectively burdened because Interveners (in order to protect those hearing rights) have had to address in their July motion and again in this motion the record reopening standards set forth at S2.734(a).
Moreover, the additional time l
required by an intervenor to locate prospective expert-or fact-affiants, prepare affidavits and otherwise prepare pleadings that will meet the " heavy burden" that reopening a record presents has to be weighed by this Board in assessing the timeliness of this filing eyen if, as Interveners contend, the i'
record reopening standards need_not_he_me.t.
Kansas _ Bas _ancL A/
Of course, the Board might reason as follows:
- 1) Record reopening is not required just as Interveners have asserted; 2)
Therefore, no affidavits were necessary; 3) As a consequence, these additional bases and contentions were filed too late because Interveners' spent an extra week obtaining affidavits that they did not need.
Of course, had the Interveners presented these additional issues on August 23 or 24 (assuming something like the Staff's desideratum - a "24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> rule" -
does apply) then the Board could have reasoned in reverse finding the record reopening standards applicable and the absence of affidavits grounds for rejecting the filing "out-of-hand."
Seabrook, ALAB-915, 29 NRC 427, 432 (1989)(adjudicatory Boards to reject reopening pleadings out-of-hand if S2.734 requirements are not met "within their four corners").
Once the Interveners had received this news, if they had than obtained the affidavits and resubmitted their pleadings, the Board could then reject them as being untimely.
The only alternative would be for the Interveners to establish a series of filings for each contention:
- 1) file immediately without affidavit or other support and then 2) before awaiting any decision, file again with affidavits addressing recpening standards.
Of course, in these circumstances the second filing could be seen as a constructive withdrawal cf the first.
No doubt the Staff will be enthusiastic about some of the arguments set out in this footnote.
In anticipation of the Staff response to this motion, Interveners state: 1)
" adjudication in this agency [is not] a game," Transcript of oral argument before Appeal Board on July 12, 1989 at 18; and 2) such a procedural shell game is not " fundamentally fair" and violates due process.
It violates due process no less to find Interveners' pleading " untimely" at the same time ignoring the time-consuming components of that pleading which Interveners considered necessary because of the inaction of this Board in resolving whether in fact those components are necessary which question 5 1tervenors themselve.s put before this Board.
See June 21 Reply at 2.
_4-
a Electric Co. (Wolf Creek Generating Station, Unit 1), ALAB-462, 7 NRC 320, 328 (1978).
One final introductory note:
again, Interveners anticipate further filings in the form of additional bases or further contentions based on not-yet-available-but-expected-information.
First, a public meeting is scheduled for September 6, 1989 at which the Applicants will discuss low-power events.
- Second, Inspection Report No. 50-443/89-07 has not yet been received and it will deal with the licensee's engineering and technical support function between June 19 and 23, 3989.
Egg reference in IR 89-06 at 1.
(IR 89-06 is dated July 28 and was received by Mass AG on August 4, 1989.)
Third, no information as yet has been :eceived in response to a series of FOIA requests to the NRC by the Mass AG.
These requests, inter alia, seek information about the low-power testing events of June 22 and 23 as well as other pertinent information.
(For example, the Applicants' July 12 CAL Response, Enclosure 4, Chronology at 22 indicates that on June 23, 1989 an already scheduled Self-Assessment Team (SAT) -
Management Oversight Committee (MOC) meeting was held to discuss, inter alia, the SAT Spe^ial Event Analysis of 9 operations and maintenance events.
It may be that these (apparently low-power) l maintenance end operational events are relevant to contentions l
now being filed or would support additional contentions.
Open l
l FOIA requests to the NRC should produce information pertinent to these nine additional events as well as possibly information about other presently unknown matters.)
1 _ _ _ - - _ _.
.i l
1.
JURISDICTION Interveners continue to rely on ALAB-916 for the proposition that'this Board in the first instance has jurisdiction over all present or future licensing issues.
l-IBIERVENORS' AIH11T TQ LITIGATE Interveners adopt in full all their arguments on the nature of their hearing rights regarding the June 22 and 23 low-power testing events set forth in the Mass AG's May 31 Motion, the Mass AG's June 21 Reply and the Interveners' July Contention.
In addition, Interveners make these additional or clarifying points:
1.
Low-power testing is ERI ng material to the issuance of a full-power license in those circumstances in which a low-power license has issued before a full-power license and testing has HEED performed pursuant thereto.
This basic relationship between the low-power testing program and the NRC's (and, therefore, this Board's) decision to issue a full-power licer.sc is indisputable.
The Staff's affiants state:
the low-power test program is part of the Seabrook initial test program.
The program is conducted to assure that the facility performs as designed and can be operated safely, that plant and emergency operating procedures are adequate, and that plant personnel are knowledgeable and prepared to operate the facility in a safe manner.
August 18 Affidavit of Partlow and Nerses at 3.
Because the Seabrook low-power test program is material to the full-power licensing decision, UCS_ymJiRC, 735 F.2d 1437, unambiguously indicates that Interveners' hearing rights are impermissible burdened by subjecting their low-power contentions to the record reopening standard.
The Appeal Board (whose holdings -
d establish the law binding on this Board) twice has recently 1
(
affirmed this relationship between materiality and the public's hearing rights.
In ALAB-918 the Appeal Board stated that the.
y UCS case-holds that a party's statutory hearing rights on a material licensing issue cannot be made to hinge upon the agency's unfettered discretion to reopen the record.
ALAB-918, slip opinion at 13 n. 21.E' In ALAB-920 (August 21, 1989) the Appeal Board, in the context of financial qualifications, held that a material licensing issue is "open to litigation by interested-parties" (slip opinion at 29)(emphasis on first two words added).
In reaching this determination, the Appeal Board cited UOS as well as the Commission's own reference to UCH in CLI-88-10, 28 NRC 573, 602 (1988).
2.
In addition, the low-power events giving rise to'these contentions were serious enough to have let the Staff to
" suspend" or " constructively suspend" the Applicants' low-power 5/
Nothing hangs on the word " unfettered" here.
At the time the reopening standard was rejected in UCS and by the court in San Luis Obispo Mothers for Peace v.
NRC, 751 F.2d 1287, 1312, 1316-1317 (DC Cir. 1984), it was not codified as it is at present at S2.734.
However, the codified standard in all I
relevant particulars was taken from then existing case law and remained discretional'y.
(If anything, the codified version became more" draconian.")
Moreover, in the codification rulemaking the Commission did not mention these cases.
51 Fed.
Reg. 19535 (May 30, 1986).
Finally, the Appeal Board's discussion in ALAB-918 makes clear that it was approving the Licensing Board's assumption (in part of LBP-89-4, 29 NRC at
- 68) that the record need not be reopened.
"The short answer to the Interveners' claim, however, is that the Licensing Board did not deem the exercise contention to be filed after the record was closed at all."
ALAB-918 at 13 n.
- 21. _ _ _ _ -
? license.
At present, the' Applicants do not have legal authority to perform the natural circulation test.E' To the'
~
i extent that Applicants or the Staff think that the Applicants
]
continue.to retain ~1egal authority'to return the reactor to criticality,,they should consult the Applicants' CAL Response,-, Chronology at 11:
8)
Vp-Np asked if it would.be acceptable to re-establish reactor criticality and then to hold in the standby mode,.
U 9)
NRC (Wiggins) responded no and Vp-Np/
NRC agreement was reached... 1/ ecause the B
Applicants' low power license'was suspended, the Interveners have a right to a hearing under the Atomic Energy Act.
5/
Interestingly, although the Applicants' obviously initiated the natural circulation. test on June 22, 1989 pursuant to their low-power testing license, after further testing was prohibited by the NRC,_this test changed its stripes and is no longer described as a " low-power" test at all but is one "usually done
.as part of the power-ast:usion program after.a full or partial power license issues."
Applicants' August 7 Response at 1, n.
2.
No doubt this metamorphosis was needed to relieve any time
. pressure on full-power licensing (which Applicants continue to believe is imminent) which would be caused by the Applicants rather inconvenient need to resecure' low-power authority'and-then complete the natural' circulation test'before a full-power license would issue.
In any event, Applicants' post facto determination that they were conducting a test usually not done j
during low-power testing only simplifies things:
obviously-the authority to conduct the natural circulation test which has been withdrawn is on authority that will be granted at the time a full-power license issued.
Thus, the issues raised by this suspension of the low-power testing authority are directly material to Applicants' full-power license.
2/
Any prohibition can be subjectively agreed to by those against whom the prohibition runs.
Often prudence would demand such an attitude.
But the agreement to conform one's behavior l
in these circumstances does not make the prohibition into a consensual, self-imposed restriction.
The substance of the actions taken (and the need for those actions in the face of the Applicants repeatedly expressed intention to restart the reactor) snd not'the form of these actions determines whether a suspension has' occurred.
Egg Commonwealth of Massachusetts v.
ERC2. No. 83-2211 (1st Cir. 1989) slip opinion at 11.
1 - - - _ _ - - _ - - _ _ _ - _ _ _ _ _ _ _ _ - _ - _ _ _ _ - _.
The Commission has created the licensing structure pursuant I
to wnich Applicants have sought and received a low-power license while simultaneously continuing to seek a full-power license.
In this posture, ones the low-power license was suspended that suspension, taking place as it does in the context of an ongoing full-power licensing proceeding, gives
' rise to Interveners' hearing rights under the AEA.E This Board has jurisdiction over the events leading to the suspension to the extent those events and that suspension must license.E If the be resolved prior to a full power Commission is free to create a low power / full power licensing sequence, it must still do so against the background of the hearing rights expressly granted to the public in the AEA.
The public has a right to litigate the granting of a license and l
the suspension of a low-power license when a full-power l
l license has not yet issued.
1 3.
The Interveners' right to litigate the low power events without successfully reopening the record is also clear B/
A " suspension" could occur in a context in which a full-power license had already issued.
Interveners claim that their hearing rights under the AEA would attach to such a l
suspension.
In any event, in this case a suspension of a low-power license occurred during the pendency of a full-power proceeding.
Thus, Interveners opposed to the issuance of the Lull power license are affected by the suspension of the low-power license, the events giving rise to that suspension, and the manner by which issues presented by those events are resolved, as they obviously must be, before the issuance of the full-power license.
R/
Thus, the low power events at Seabrook have both an enforcement aspect and a licensing aspect.
Whatever procedures may be available to structure a hearing pursuant to the enforce. ment of the terms and conditions of the low-power license, Interveners claim a right to litigate that suspension (the events leading to it and the steps taken in response) as it pertains t o the full power licensing process.
_9_
from the Staff's actions.
The Staff is reviewing and evaluating the efficacy of Applicants' purported " corrective actions."
Staff's August 18 Response to' July Contention at 18.
Obviously, since the Applicants no longer intend to conduct any testing pursuant to (or otherwise exercise) their low-power license, the Staff's review and evaluation of the Applicants' remedial actions can only be connected to a Staff finding that the Applicarits are prepared to receive a full-license.1E#
But if the Staff is again reviewing and power evaluating certain licensing issues pursuant to a Staff recommendation that a full power license should issue,11/
then those issues are material to that licensing decision.
The Appeal Board has held that Staff Review of issues not otherwise 12#
material to licensing 10/
Thus, again, the enforcement aspect of the Staff's actions by necessity have yielded to the licensing aspects since the Applicants proudly disclaim any further need for the low power license whose terms and conditions they violated.
l 11/
If the Staff is trying to decide whether the remedial actions are sufficient to justify reinstatement of the low power testing license then it is engaged in an academic inquiry.
The Applicants no longer seek authority to conduct testing pursuant to the low power license but only seek now a full power license.
12/
In ALAB-920, those issues were barred by the financial qualifications exemption for electric utilities.
Here the l
L Applicants and Staff contend that the issues are barred from i
litigation (in the absence of a closed record being reopened) because the issues have been resolved in the Applicants favor at the point at which a low power license issued.
Obviously, the Staff in suspending the low power license and in setting itself the tasks of reviewing and evaluating the efficacy of Applicants' purportedly remedial actions, has made these issues again material to licensing. - _ _ _ _ _ _ _ _
l is grounds for opening up such issues to litigation by other interested parties.
ALAB-920 (August 21, 1989) slip opinion at 1
28-29 (quoting the Commission to the effect that'the " Staff l
cannot have it both ways").
In effect, the Staff wants to reopen the licensing record on a tange of issues arising out of the low power events but not invite the Interveners to I
participate. ' precisely such confused meandering by the Staff lead to a relevant part of the holding in ALAB-920.
4.
Of course, just because the low power testing events giving rise to the filing of these contentions are themselves material to a full power licensing decision, it does not follow that Interveners' contentions must be admitted for litigation.
Obviously, although Interveners' low-power contentions and their accompanying motions do not need to address record reopening standards, the contentions must meet the standards for admissible contentions:
adequate basis and specificity.
The additional bases to JI-Lp-l and the new contentions all allege adequate basis and specificity.
Specifically, these bases and contentions all allege problems pervasive enough to affect a decision to license.
Obviously, the Staff agrees because based on the low power events it has precluded for the present the Applicants from further licensed activity, thus acknowledging by its actions that the issues raised affect the -
' decision toilicense-to operate.13
' LATE-f1 LED._COMTEliTION STANDARD A.
Good-cause, if any, for failure'to file on ting.
"On_ time" in the S'eabrook proceeding has recently been
~
interpreted to mean 15 days prior-to a prehearing-conference Lthat was'hel'd sometime'in the spring of 1982.1A#
ALAB-918 slip opinion at 11-Obviously, neither.the Interveners, nor-the Applicants, nor the Staff,~nor the Seabrook Licensing Boards sitting on various phases of this proceeding knew that every contention filed since 1982 was late-filed no matter what filing deadline'had been set.
In any event, the filing 11/
If the. Staff were to take the position in' response to the-attached additional bases and contentions that it took in response to the July Contention that nothing is raised here thatois of-sufficient weight to affect a licensing decision, then it would be trying to have it both ways in another sense.
'Obviously,'the Staff by its actions determined-that the-low power events on June 22 and 23, no-matter how marvelous the Applicants' netformanga up to that time had been, were, sufficient to affcct a licensing decision.
Indeed, the Staff made a licensing decision in an enforcement setting:
it suspended the low power license.
Now, in the licensing. setting the. Staff pretends that ti,e same events when out in context are merely an aberration not sufficient to affect a licensing
- decision.
The Staff only undermines the basis for its own
~
enforcement actions in this curious tour-de-force in not letting the right hand (or right hemisphere) know whet the left hand (or hemisphere) is doing.
In any event, the Staff, if it now believes the events do not affect licensing, should apologize to the Applicants and give them back their low power license (the return of which they have studiously avoided).
In the absence of such a self-immolating act of apology, the Staff E
at the very least should be estopped from reversing field 1800 before this Board.
(The Mass AG has already stated its belief that Staff methods of conducting litigation merit sanction.
Mass AG's June 21 Reply at 12 n.10.
Obviously, there is.nothing ad hqc about the Staff's recurring difficulties with consistency.
Cf. ALAB-920 at 28-29.)
11/
Cf. Interveners' July 10, 1989 petition For Review of ALAB-918 at 2-3.
On August 18, 1989, ALAB-918 became final agency action when the Commission did not take review. _ - _ - _ - _ _ _ _ _ _-____ _ ___ - - -_-_ -
l deadlines for contentions set by various Boards (including this one, must recently pursuant to an August 19, 1988 Order for June 1988 exercise contentions) at the very least establish " good cause" for the late-filing.
The Mass AG sought precisely such a schedule from this Board in his May 31 Motion so that he could meet it.and thereby make out " good cause" without engaging in a j
rather bizarre quessing game about when contentions have to be filed.
May 31 Motion at 9-10, n.2; June 21 Reply at 3, n.2 and 3.1E#
These efforts alone by the Mass AG to have this Board set a filing deadline constitute " good cause" for filing these additional bases and contentions at this point.
The Interveners have received information about the relevant low power events in bits and pieces and as noted have had to judge with regard to any possibly litigable issue when that information is sufficient to " start the clock."
Of course, Interveners have no idea how long the clock, once started, is going to tick in the absence of a filing deadline.
In these rather remarkable circumstances, Interveners have proceeded as follows:
- 1) in light of available information they have scoped out all potentially litigable issues arising out of low power testing; 2) they have kept separate records for each such issue and determined when sufficient information on each discrete issue has become 15/
For example, this Board could have set 30 days from the date of receipt by Interveners of relevant Staff Inspection Reports.
As noted above, this Board could also have resol"ed the legal issue whether these contentions must be accompanied by a motion to reopen the record thereby shortening the time needed to prepare these pleadings (and to read them) and also justifying a shorter time for filing after receipt of sufficient information by Interveners.
Instead, the Board simply deferred ruling.
What goes around, comes around. !
1
h
- - i. '
< r k
.available; 3)ithey,have then immediately sought out experts i'
knowledgeable about these discrete issue areas, conveyed the information gathered on that issue'toLthat point to those 1
L i
experts and'obtained. expert affidavits setting forth factual.
and technical bases for reopening the record; and 4) they have
.then. prepared' accompanying motions addressing all admissibility issues in as detailed a fashion as they believe is called'for by the circumstances.1E' To date, this process has resulted' in a July 21 and this August 28 filing.
The July 21 filing was
. triggered by the additional 1information set forth in the Applicants' CAL Response received on July 14, 1989.
This present-filing was triggered by the Staff's AIT and by Staff affidavits accompanying the Staff's August 18 Response all received August 22, 1989.
(The AIT and the Staff Affidavits received on August 22, 1989 are incorporated by reference into the body of this' motion.)
In-light of.the circumstances this
. filing is timely.
B.
Protection of Interveners' Interest The Interveners adopt their statements on pages 16-17 of the July 23 Motion.
15/
The Mass AG, if necessary, will submit affidavits of his attorneys detailing time spent on the Seabrook proceeding since June 22, 1989 assuming this is relevant.
Oral argument was held on Seabrook matters on July 12 and July 27, 1989.
' Hearings ended before this Board on June 30, 1989.
proposed findings were-filed by the Mass AG on August 14, 1989.
The Applicants sought an exemption from another pre-licensing onsite exercise to which the Mass AG responded in detail on August 121,-1989. -
C.
Development of a Sound Record l
The issues Inte-venors now seek to raise are set.forth in the July Contention and the additional basis to it and the other contentions attached hereto, all of which are specifically incorporated by reference into this motion.
The expert witnesses the Interveners will provide are Gregory C. Minor and Steven C. Sholly.
Their affidavits and professional qualifications are attached hereto and incorporated by reference.
The testimony they would have offered is put forth in summary fashion in their second affidavit which is attached hereto and incorporated by reference into the body of this motion.
Interveners also incorporate by reference pages 17-24 of their July 21 motion.
D.
14hether Interest RepI.esgrigd_By Exi;itina Parties In this proceeding, no other party has raised or is raising the issues set forth in the additional bases to JI-LP-1 and the other contentions.
The Staff is reviewing some, but not all, of these matters outside the proceeding but the Interveners' interests will not be represented by the Staff.
E.
Broaden or Delay the Procggdinq l
Although the admission of these contentior.s will broaden the issues in this proceedina several of these issues are presently being reviewed by the Staff.
Moreover, it is not clear that admission of these contentions will delay full-power licensing in light of future potential litigation arising out of the Applicants' financial qualifications; the next onsite emergency plan exercise or the Commission's determination of an exemption 1
therefrom for the Applicants. i l
i
MOTION TO REOPEN THE RECORD Before discussing the reopening standards in detail, Interveners point out that the affidavit requirement of 10 C.F.R.
S2.734(b) should not be rigidly interpreted as an absolute requirement for a successful motion to reopen.
- Where, as here, the factual bases for the movants' claims are set forth in NRC and Applicants' documents, Interveners make out sufficient grounds to reopen the record, if they adequately address each of the 3 criteria and identify with particularity the issues they seek to litigate and "the factual and/o1 technical bases" that they believe supports their claim that each issue is timely raised, safety significant and demonstrates that a materially different result would have been likely.
10 C.F.R. S2.734(b) (emphasis supplied).12#
The issues raised by the additional bases to JI-LP-1 and by the other contentions are identified with particularity in the contentions themselves which are attached hereto and incorporated by reference into this motion.
The issues are also identified by Interveners' affiants Minor and Sholly and their affidavit attached hereto.is incorporated by reference into this motion.
12/
The movant and nat the affiant is to identify the j
particular issues and specify the factual and/or technical 4
basis for each issue that makes it timely raised, safety significant and material.
Id.
The affiant, as would be expected, is simply to provide the factual and/or technical bases for the movant's claims in this regard.
The movants make these claims and not the affiants.
t i
I
! t
b I
'i y
A.
Timeliness-The Interveners incorporate their statements set forth above and in the July' Contention regarding the timeliness of this motion.
The' specific factual and/or technical bases supporting the claim that each of the issues' identified is
' timely raised are set forth in the body of those bases and contentions and in the accompanying Supplemental Affidavit of Sholly and Minor which are-incorporated herein.
The AIT, the accompanying Staff affidavits and the Staff's Enclosure 2
" Enforcement Conference Issues and Related Regulatory Requirements"'were received August 2 2,- '1 9 8 9.
(All of these documents are incorpor.ated by reference into the body of this motion.)
In additior, certain of the issues presented by this motion represent exceptionally grave issues.
.B.
Safety Significant The accompanying additional _ bases and contentions raise significant safety issues.
The AIT states:
The failure of the operating crew to trip the reactor when required by the test procedure during the June 22nd test; the failure of test group personnel to recommend tripping of the reactor at that point and the failure of management present in the control room to exercise their responsibilities in this situation, despite the' fact the plant was being operated under a Technical Specifications Special Test Exception, is safety significant.
Also, the apparent willingness of management to proceed with testing following the June 22nd occurrence without first completing a thorough review and causal factor assessment is safety significant.
l AIT at 6.2.
Not only has the Staff stated that these issues h
are safety significant, but the Staff's actions in suspending L
l: - __ _ __---- - --__ - - _ _ - - _
or constructively suspending further licensing activity pending licensee remedial actions establishes that the issues y
identified in these additional bases and contentions are safety significant.
In addition, the failure of OC/QA to assure operational quality during test procedures is safety significant.
Effective and adequate monitoring and oversight of testing operations by QC/QA is a necessary component of part 50 Appendix B's requirements for a quality assurance program.
' poor maintenance practices, inadequate administrative controls over maintenance and inadequate quality control and quality assurance oversight over maintenance practices are safety significant.
Effective and careful maintenance is essential to safe plant operation as is clear from part 50, Appendix B, Introduction and XVI.
The specific factual and/or technical bases supporting the claim that each of the issues raised in the accompanying additional bases and contentions are safety significant are set forth in the body of those bases and contentions and the Supplemental Affidavit of Sholly and Minor which are incorporated by reference into the body of this motion.
C.
Materially Different Result Would be or Would Have Been Likelv The issues presented in the attached additional bases and contentions have not been previously litigated and have not previously been in controversy among these parties.
Had these issues and contentions been adjudicated the deficiencies and
{ I i
I i
inadequacies in the Applicants' operator and management training., administrative controls, QC/QA programs, startup readiness, maintenance programs and management character as reflected in Applicants' lack of careful and thorough post-trip review prior to seeking restart would have led to a materially different result, y11 no operating license would have issued to Applicants.
The specific f6ctual and/or technical bases supporting the claim that each of the issues raised would have likely produced a different result are set forth in the body of those bases and contentions and in the accompanying Supplemental Affidavit of Sholly and Minor which are incorporated herein.
CDRC1&SLOR For all the reasons set forth above, this Board chould admit the contentions attached as Exhibit 1 hereto for adjudication.
Respectfully submitted, l
COMMONWEALTH OF MASSACHUSETTS JAMES M.
SHANNON ATTORNEY GENERAL f
CW G A6h'n Traficonte I
Ashistant Attorney General ief, Nuclear Safety Unit Matthew T.
Brock Assistant Attorney General Nuclear Safety Unit Department of the Attorney General One Ashburton Place Boston, MA 02108-1698 (617) 727-2200 DATED:
August 28, 1989 I
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}4 EXHIBIT l' 2
LLOW POWER CONTENTIONS
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I I-LP-1: [As. Filed On July 21,.1989]'
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l ADDITIONAL'BASESh t
F.
The AIT Report makes clear that inadequate training W~
was revealed by.the June 22 events.
This inadequate training
- and;the poor operational quality-that resulted from'it was in-violation of 10 CFR 50;' Appendix B
- , Criteria V requiring
' adherence to appropriate procedures, XI requiring adherence to test procedures; and'the.FSAR S 14.2 requiring'that'the initial' start-up testing-be administered in accordance'with' procedures-.
1.
The Start-up Test 1-ST-22 pre-test briefings ~were.not
. conducted asJrequired in that Test Step 3.2 which required all personnel involved withLprocedure performance to'be briefed w's a
not followed.
One of the two control board operators and the shift supervisor (SS) were not briefed.
(AIT at'5.l'3, 5.2.4)~
, The AIT is incorporated herein in full.)
The briefings that
(
' were conducted were abbreviated and fragmented and not given to the operators as a group.
(AIT at 5.2.4, 5.2.6).
.These briefings were not effective in communicating needed information'to the. relevant personnel.
(AIT at 5.1.5 (shift
- supervisor was not aware of the complexity of the test); 5.1.5 (operators.did not trip reactor when trip level was exceeded)).
In fact, the Test-Director briefed the management observers and t
_.__.__m_ _. _. _ _ _ _ _ _ _ _ _
l non-participating operators immediately prior to the test, but.
l this briefing was also not effective in conveying either the substance or the importance of the test criteria, because none of these individuals suggested manual trip during the test.
AIT at 5.1.3.
In fact, not one of these seven managers present, including the VP-NP, the Operations Manager, the Assistant Operations Manager, the Station Manager and the Assistant Station Manager prior to the test knew the trip criterion and of these seven only the Station Manager knew there even was such a test trip criterion.
AIT at 5.3.3, 5.3.1.
2.
In addition to the pre-test briefings required by the i
Test Procedure, the Seabrook Operations Management Manual (OpMM) at $1.8 requires shift crew evolution briefings.
If evolutions involve many individuals (as this test procedure as performed on June 22 did) large formal briefings or planning sessions may be required.
(AIT at 5.1.3).
These briefings should include five elements including a review of precautions and limitations.
No such shift crew briefings pursuant to OpMM S1.8 took place at all.
Id.
In fact, individuals were' briefed separately and not before but during their shift.
Id. Not all the operators had reviewed the test procedures in detail before their shift began.
The CROs were given copies of test manual remetor trip criteria just prior to the test.
The SS was not even briefed at all.
AIT at 5.1.3.
No corrective actions with regard to the OpMM and the pre-shift briefings required for complex evolutions is mentioned in CAL.'esponse, Enclosure 1 at 3-4. _ _ _ _ -
3.
The training of those with operational responsibility for this test prior to the briefings described above was inadequate because no recent training had been afforded-.
(AIT 5.1.2, 5.1.5).
In addition, the' simulator training offered in April and May 1986 was received by the SS, the USS and two of the four CROS with operational responsibilities during the test.
(AIT 5.3.2).
That training was act received by the SCRO or the other two CRO with operational responsibilities during the test.
Id.
After the classroom training offered in September and October 1988, NRC inspectors indicated that simulator training was appropriate prior to start-up testing.
The Applicants represented to the NRC in October and~ November 1988 that they would consider more effective use of the facility simulator in future startup training.
Inspection Report 88-15 at 8.
Even though NHY had used the simulator in 1986 and had been advised to do so again in November 1988 by the NRC prior to start-up testing they did not do so.
- Moreover, NHY's Self-Assessment Team (SAT) had determined that because of the extended length of time that the plant had been in cold shutdown refresher training was a prerequisite for safe and reliable plant operations.
Inspection Report 88-15 at 9.
This refresher training was offered in the form of classroom training in September and October 1988.
AIT at 5.1.2.
Even though there was another nine months of delay before the start-up program was actually begun and the SAT had found it to be a prerequisite NHY did not offer any refresher training after October 1988.
Moreover, although the general training of i
.3 -
L.. _
those with operational responsibilities during this test included the instruction that procedures must be adhered to and specifically that reactor trip criteria if exceeded should result in a reactor trip, none of these individuals' actions ref}ect.that this training and instruction had been adequate.
4.
The training and qualifications of the Shift Supervisor, the senior on-shift manager, were inadequate and resulted in poor operational quality during this test.
The SS was responsible for control room command, AIT 5.1.1, and had the authority to shut down the reactor.
He had delegated command to the USS.
AIT at 5.1.1.
He was never briefed about the 1-ST-22 test nor did he have a copy of the test procedures available to him during test performance.
AIT at 5.1.3.
Although the SS knew at the time that the pressurizer level was below 17% he was not aware of any manual trip requirement.
AIT at.5.1.4.
Because the natural circulation test is one of the first evolutions performed with a critical reactor, and involves abnormal operating conditions, the SS should have been knowledgeable and involved in test operations.
AIT at 5.1.5.
He was not adequately trained or qualified for his responsibilities.
l 5.
The Start-up Test Group (STG) was not adequately trained and qualified to perform its duties during the start-up test program.
The STG has overall responsibility for the initial start-up testing program.
During the Natural Circulation Test, the Start-up Supervisor was the Acting Shift l
,r'-
.jo g
b
~ Test Director..The Start-up Manager, to whom the start-up Supervisor reports, the Start-up Supervisor and the Test' Director-(TD) were in the control room.- AIT at 5.2.1.
The Test Director performs all requited briefings for each test and
- he has the responsibility for verifying that all individuals involved are Driefed as a prerequisite to each test procedure.
Inspection' Report 88-15 at 8.
In fact, the Test Director' represented -that all relevant individuals had been briefed when L
he initialed the test procedure a few hours prior to the l
tests. 'AIT at 5.2.4.
In fact, the SS had not been briefed nor had one ofLthe control board operators.. AIT at 5.1.3, 5.2.4.
The crew had also not been> briefed pre-shift as a-group.
AIT at 5'.2.4.
In,IR 88-13 at 22 the staff noted a concern that a test director was not qualified pursuant to the requirements of 1.
the FSAR.
The Start-up Manager and the Acting Shift Test Director both had authority to terminate the test if plant conditions are not as specified in the test procedures.
AIT at 5.2.1.
Neither of these individuals took any steps to terminate the Natural Circulation Test after pressurizer level dropped below the manual trip level.
AIT at 5.2.1. No e
classroom training was offered the Test Director or the Acting Shift Test Director on transients that might occur during start-up testing.
AIT at 5.2.3.
Although the Acting Shift Test Director and the Test Director met the training requirements for their respective positions as described at
$5.2 of the Start-up Test program Description, Rev. 2, AIT at 5.2.3, this training was simply not adequate to enable the l l
start-up personnel to function effectively to coordinate and direct test activity.
No members of the Start-up Organization are operator license holders, AIT at 5.2.3, and presumably this may have resulted in the failure of any intervention by the start-up personnel during testing.
The Start-up Manager, who was in the control room but not in the operating area, became aware that the 17% trip criteria had been exceeded when an NRC inspector told him the criteria had been exceeded.
AIT at 5.2.5.
Although the Start-up Manager appeared to hear the inspector's statements he:
continued to watch the in-progress test, appeared to take no action, and gave no oral response.
AIT, Appendix F at 2.
The Test Director, who was the only member of the start-up staff inside the operating area, became aware that the trip criterion was exceeded when the control board operator announced that letdown had isolated.
AIT at 5.2.5.
Instead of recommending to the USS that the reactor be tripped, the Test Director instead indicated to the USS that he would begin monitoring computer trends for Tavg to ensure that the 15-minute Technical Specification on Lo-Tavg was not violated.
By performing this task the Test Director removed himself from a position in which he could perform his oversight duties.
AIT at 5.2.5.
Moreover, the USS at the time that the trip criterion was exceeded told the TD that one of "your l
limit [s]" was exceeded.
AIT at 5.1.4.
The TD took no steps to 1
)
correct the USS's misinterpretation of the very nature of the test limits.
Shortly thereafter, an NRC inspector told the TD j
thbt the reactor was being operated below the level requiring a manual trip.
The TD then connunicated to the USS that the NRC had a problem with continued operation below the trip
. criterion.
Upon being told by the USS that the problem was being handled, the TD returned to his monitoring of the Tavg and did not recommend that the reactor be tripped.
AIT at 5.2.5.
Finally, the Acting Shift Test Director who was aware of the trip criterion and that it had been exceeded apparently focussed on analyzing the transient and failed to perform any advisory role at all.
AIT at 5.2.5.
In short, the Start-up personnel whose responsibility it was to coordinate and direct test activities and who were able to either stop the test (Start-up Manager, Acting Shift Test Director) or recommend stopping the test (TD) totally abdicated their responsibilities.
In IR 88-13 at 23 the staff noted that changes had been made in the Startup Program Description manual.
These licensee changes sought to provide the Startup Group with "more detailed clarification and direction during the performance of tests that do not go as planned" including guidance for the
" interruption of tests."
The Startup Group did not evidence any capacities in this regard.
In essence, there was no one performing the test coordination and direction function.
6.
prior to the conduct of this test, the Applicants had created a Nuclear Quality Group (NQG) which is responsible for carrying out the Operational Quality Assurance Program (OQAP) in an effort to meet 10 CFR 50, Appendix B.
The NQG has a staff of 55 persons.
Prior to this test, the NOC had assigned __-..--_ __ __ _ __ _
two quality control personnel and one quality assurance surveillance personnel (who is also a senior reactor operator qualified person) per shift.
These NQG personnel were to provide shift coverage until the completion of low-power testing.
Inspection Report 50-443/89-80 at 10.
These personnel had received special briefings, reviewed inspection guidelines for low-power testing apa reviewed the start-up test procedures.
ldm at 10-11.
In fact, the licensee's Self-Assessment Team had recommended that before initial criticality the NOG personnel assigned to low-power testing activities obtain the requisite technical and operational expertise and have additionel training ostensibly to perform their functions during low-power testing.
Apparently, this had been 6 accomplished.
Id at 11.
Nonetheless, no mention of any actions of these NQG personnel is made in either the Applicants' CAL Response of July 12 or in the AIT.
CAL Response, Enclosure 4 at 5 (identifying 3 QA/QC personnel.)
Moreover, these personnel appeared to have played no role in the post-trip review process.
CAL Response, Enclosure 4, Chronology at 7; AIT, Chronology of Communications at 2-3.
No corrective actions are proposed at all with regard to the performance of these QA/QC personnel during and after the events.
Yet during the activities leading to low-power testing, the staff had observed that 0A/QC personnel had " interfaced well with the i
operations staff."
Inspection Report 89-80 at 5.
No QA/QC personnel appeared to have even noted the absence of any pre-shift briefing pursuant to OpMM SI.B or the poor quality _ - _ - - _ _ _ _ - _ - _ _ - - _ - _ - - _ _ _ _ - _ _ _ _ _ _ _ - - _ - - - _ _ _ _ - _ - - _ - _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _
brief ng pursuant to the Start-up Test program.
Weaknesses in the NQG's. capacity to ensure operational quality led the NRC Staff to recommend on March 1, 1989 that the " Licensee conduct an' independent investigation of the status of quality activities
- at Seabrook, better define how the broad mandate of the OQAP is to be implemented.and evaluate the working interface between the station staff and the nuclear quality group."
Inspection Report 89-03 at 26.
This was not adquately accomplished.
All of these circumstances involving QA/QC personnel indicate that 10 CFR Part'50 Appendix B Criteria I, II, XVI, and XVII have been violated.
G.
The AIT Report indicates that inadequate administrative and quality controls exist to ensure that proper maintenance procedures are employed.at Seabrook.
Thus, maintenance activities are not in accordance with 10 CFR 50, Appendix B, V, XIc XVI, and ZVII.
1.
The Applicants stated in their CAL Response, Enclosure 4 at 29-30 that an open work request existed on steam dump valve MS-PV-3011 pending a retest of the valve after some corrective maintenance subsequent to the Second Seabrook Hot Functional during February 1987.
The Applicants also stated that the valve was not " operable" at the time of the natural circulation test as operability is defined by the Seabrook Station Maintenance Manual.
Further, the Applicants represented that the test rtquired as a prerequisite that the valve be operable.
Finally, the Applicants represented that:
( -
= _ - _ _ - _ -
System availability was specifically considered and was determined to be satisfied by virtue of the stystem use during the Emergency Feedwater System testing completed on June 12, 1989 and use during the June 22, 1989 pre-Natural Circulation Test preparatory activities just prior to 1-ST-22
]
performance.
j CAL Response, Enclosure 4 at 30.
In f act, we learn only in the AIT at 14 that a test prerequisite was signed off confirming the availability of this steam dump valve, even in the face of the open work order.
It appears likely that on June 12, 1989, other separate testing was performed - the Emergency Feedwater System testing - even though at that time as well an open work order for the valve existed.
IR 89-07 at 8 makes reference to a concern first set forth in IR 88-11 that Seabrook personnel were " reporting notification work items as complete when they actually were incomplete".
Thus, there did exist some controls in the Start-up Test Program to ensure that all relevant Work Requests were closed out prior to testing, but the test prerequisite was simply signed off notwithstanding the fact that the valve was not operable.
C12 CAL Response, Enclosure 1 at 3.
Such actions may reflect inadequate maintenance and control practices that have arisen in light of large maintenance backlogs and continued financial and licensing pressure.
H.
[This additional basis is also proffered as a separate contention and designated "JI-LP-1A"]
The AIT Report makes clear that management training, orientation, character and objectives prevented an appropriate and adequate response by management to the failure of the test and operations personnel to manually trip the reactor at the _- __ ___
_____________--_-______-___a
point at which the trip criterion was exceeded.
The low-power events, thus, indicate that the Applicants are in violation of 10 CFR 50, Appendix B, Criterion XVI, the FSAR Chapter 13.1.2.2 and Technical Specifications 6.2.1.
b, c, d.
Licensee management's main thrust following the test events eopeared to be to resolve any hardware problems necessary as soon as possible in order to resume testing.
Licensee management did not appear to grasp the significance or extent of the test and operational personnel's improper conduct and procedural non-compliance or plant malfunctions and did not evidence any intent to inquire further before resuming operations.
Management did not appreciate the need for self-evaluation,
~
self-assessment or root cause analysis before resuming operations.
1.
The Vice-President for Nuclear Production (VP NP) convened a licensee management meeting at 1:00 p.m. on June 22, 1989, AIT, Appendix B at 2, only 15 minutes after the Deputy Regional Administrator had informed him of the NRC's concerns about the testing events.
Id.
This meeting is described in the CAL Response, Enclosure 4, NHY Management Effectiveness Chronology (" Chronology") at 4.
The Applicants assert that at l
this meeting the VP NP discussed what activities and actions needed to be taken prior to restart.
Ld.
Allegedly:
l The VP NP stressed the importance of a complete l
and thorough review of the activities leading to and following the trip prior to plant restart.
Id.
However, the AIT, Appendix B at 2 makes clear that at this 1:00 p.m.
meeting, management set the morning of June 23 for (
y a
restart.
In fact, in'a conversation between Vp NP and:the President /CEO at'l:50 on June 22, the actions necessary-for restart were discussed and identified as post trip review, valve troubleshooting and short term procedure adherence resolution.
At the same time physical plant readiness for restart was. estimated to be 7:00 a.m. June 23, 1989.
CAL Response, Enclosure 4, Chronology at 5.
Similarly, the AIT-makes clear that licensee management was not interested in a careful and detailed assessment of the events before resuming testing.
In the CAL Response, Enclosure 4, Chronology at 5, Applicants assert that pursuant to NHY Procedures 12810 and 12830, an' Event Evaluation'and Root Cause Analysis was begun at 13:30 on' June 22, 1989.
In fact, the AIT chronology, Appendix B at 3 states that at 1:50 p.m. June 23, only after the CAL issued at approximately 12:00 p.m.,
did the Event Evaluation and Independent Review Teams get established:
An in-depth review of the cause or causes leading to the improper. conduct of the 1-ST-22 natural circulation test apparently did not take place prior to an initial management decision to resume testing.
An extensive review of this event was not completed by the Licensee until after the NRC raised this issue with licensee management.
AIT at 5.3.4.
Indeed, the Station Manager indicated that he recognized that the testing f ailures were a "significant problem" ar.d that he had not been able to conduct a full discussion with his team prior to a 4:30 p.m. June 22 meeting with the VP NP.
AIT at 5.3.3.
Nonetheless, this 4:30 meeting was called to prepare the licensee position in anticipation of a 6:00 p.m.
telephone conference with the NRC.
Not only did l
_____-________-___-__-_L
,,p.
the 4:30 management meeting result in a decision to seek to restart the'next morning, but the Station Manager, who believed there.was a "significant problem" participated in that 6:00-p.m. telephone conference.
CAL Response, Enclosure 4, Chronology at 10.
This indicates a porvasive. operating and licensing pressure on management that affects its ability to l
ensure safe' operations, in that management is prepared to 1
operate the facility whether or not operation is safe andlin compliance with regulatory requirements.
'2.
Not only did licensee management ignore the human performance and procedural aspects of the events but. management concluded at 1:50 on June 22 that the physical plant aspects of the situation could be resolved by 7:00 a.m. June 23, 1989 and the reactor restarted.
In fact, the focus of the conversation between TTP NP and the President /CEO at 13:50 on June 22 appeared to be the single malfunctioning steam dump' valve:
"PV-3011 troubleshooting / repair / operability determination-or
-isolation."
CAL Response, Enclosure 4, Chronology at 5.
The AIT makes clear that: 1) MS-PV-3015 as well as MS-PV-3011 did not operate properly, AIT at 4.2.1; 2) 7 of the 12 steam dump valves showed binding, scored stems, loose on tight linkage, AIT at 4.3.3; and 3) post-maintenance testing had never been performed on MS-PV-3011.
This management response to hardware failures -- to focus on only one valve end to " isolate" it if necessary to resume testing -- violates 50 CFR Appendix B, Criterion XVI and Technical Specification 6.2.1.c..
_____m. _ _... _ _. _. _ _ _ _ _ _ _ _ _ _ - _ _ _. _ _ _ _ _
W; 3.
Deficiencies in licensee management's corporate character and orientation are pervasive and reach beyond the VP NP to-the President /CEO.
First, the President /CEO knew of the
-reactor trip as a result of a 1:50 p.m. June 22 telephone conversation with the VP NP.
Second,-he knew or should have known that a careful assessment-'of both hardware and personnel performance wasicalled for.
Nonetheless, he'discossed with the.
VP NP at 1:50 p.m. June 22 restart the next morning.
The Applicants, in CAL Response, Enclosure 4 at 22, go to great
-pains to protect the President /CEO claiming that'he was'not aware, as a result of a 11:15 p.m. June 22. telephone conversation with the VP NP, of'the licensee's' earlier 6:00 p.m.
proposal'to the NRC to restart the next morning.. However,
.the: President /CEO did participate in a 6:45 a.m.
telephone conference on June 23 prior to the 7:30 a.m. telephone conference with the NRC.
CAL Response, Enclosure 4, Chronology at 16.
This 6:45 a.m.
conference included all key licensee management personnel.
The President /CEO also participated in the 7:30 a.m. telephone conference at which aoain, as the AIT makes clear, the licensee sought almost immediate restart.
AIT at 5.3.3, Appendix B at 3.
Sag also, CAL Response, Enclosure 4 at 23 (all actions prerequisite to restart could be 2esolved prior to 10:30 a.m.
that day).
The President /CEO was participating in that telephone conversation.
Thus, as a
" corrective action" in response to pervasive licenseo management deficiencies in responding to the June 22 events, relieving the VP NP of his duties is incomplete.
As Staff - _
l l
1 Inspection Report 89-03 at 4.noted'about a series of incidents, 1
they "taken as a'whole may~ indicate a declining trend in the<
l
)
attention being paid to detail in day to day plant operations, testing and maintenance."
The licensee itself noted in an April 1989 LER that "the need to change the culture of plant personnel was discussed at'several staff meetings between April j
~
27 and 14ay 2, '1989. "
The licensee formed an ad hnc task force to " study steps needed to minimize human errors and to provide timely and accurate assessments of operating events."
Staff IR 89-05 at 10.
Deficiencies in corporate character and' orientation also extend to licensee management who at 1 p.m. on June 22, less than'l/2 hour after reactor trip, nevertheless scheduled restart for the morning of June 23.
AIT, Appendix B at 2.
Licensee' management also participated, and apparently concurred in, efforts by the President and VP-NP to push for immediate restart prior to investigation or corrective action, through
~their participation in the above cited conference calls at 6:45-a.m.
and 7:30 a.m. on June 23.
CAL Response, Enclosure 4.,
i Chronology at 16.
1 JI-Lp-2:
Low-power testing has disclosed serious defects in the maintenance practices regarding valves and the quality control of such maintenance practices and the possibility of design defects in certain steam dump valves, in violation of 50 CFR App,endix B, V, XI, and XVI, i
A.
The Applicants stated in their CAL Response, Enclosure 4 at 29-30 that an open work request existed on steam dump - -. - - _ _ - _ _ _
valve MS-PV-3011 pending a retest of the valve after some corrective maintenance subsequent to the Second Seabrook Hot Functional during February 1987.
The Applicants also stated that the valve was not " operable" at the time of the natural circulation test.as operability is defined by the Seabrook Station Maintenance Manual.
Further, the Applicants represented that the test required as a prerequisite that the valve be operable.
Finally, the Applicants represented that:
System availability was specifically considered and was determined to be satisfied by virtue of the stystem use during the Emergency Feedwater System testing completed on June 12, 1989 and use during the June 22, 1989 pre-Natural Circulation Test preparatory activities just prior to 1-ST-22 performance.
CAL Response, Enclosure 4 at 30.
In fact, we learn only in the AIT at 14 that a test prerequisite was signed off confirming the availability of this steam dump valve, even in the face of the open work order.
It appears likely that on June 12, 1989, other separate testing was performed - the Emergency Feedwater System testing - even though at that time as well an open work order for the valve existed.
IR 89-07 at 8 makes reference to a concern first set forth in IR 88-11 that Seabrook personnel were " reporting notification work items as complete when they actually were incomplete".
Thus, there did exist some controls in the Start-up Test Program to ensure that all relevant Work Requests were closed out prior to testing, but the test l
prerequisite was simply signed off notwithstanding the fact that 1
l the valve was not operable.
Cf1 CAL Response, Enclosure 1 at i
3.
Such actions may reflect inadequate maintenance and control -__ -
a
- practices that have arisen in. light of large maintenance'
-backlogs and continued financial and licensing pressure.
B.
The AIT disclosed that upon inspection seven of the
-twelve steam dump valves showed binding, scored stems, or loose or tight linkages.
AIT.at 4.3.3.
The history of steam dump-
- valve system work orders and.the post-event testing of these valves indicates there is either:
1.
a design. defect; 2.
an inadequate maintenance schedule; and/or.
3.
an inadequate test and. verification program; and/or 4.
an inadequate quality control / quality assurance program for such maintenance.
C.
This failure to establish and maintain operable steam dump valves may indicate a more pervasive deficiency in the testing, verification and maintenance of valves in general.
In IR 89-80 at 7, an NRC inspector' expressed concern that an unqualified individual was testing a valve.
IR 89-80 at 7 and 8 also reports valve difficulties which the licensee in part
'was still " troubleshooting" at the end of the inspection.
IR 89-03 at 30-31 notes another valve failure and adds:
The evaluation of the failure in accordance with the station information report process will determine.if maintenance procedure revisions are j
required.
Additionally, similar valve configurations in'other systems will be evaluated for similar defects.
The deportability of this i
failure per 10 CFR and Seabrook Technical Specifications is under evaluation.by NHY.
J JI-LP-3:
The Applicants' performance during low-power testing discloses that they do not have adequate staff and procedures and otherwise are not capable of safely conducting start-up testing pursuant to the test program set forth in the U----_:-_-_--~__
\\
ti
- FSAR at.14.2.
Start-up readiness is obviously a prerequisite to a full-power license because testing is performed in the initial and ongoing phases of power ascension after a full-power' license is' sues.
The capacity to safely conduct L
testing'is essential for the issuance of a full-power license.
The Applicants *L deficiencies in this regard violate 30 CFR Appendix B, V, XI; FSAR, Chapter 14; 10 CFR 50.34(b)(6)(iii);
and 10 CFR Appendix A; GDC 1, 14, 16, 21, 30,.31, 32, 37, 40, 43, 46, 53, and 54 (all of which require testing of specific sytems and components).
A.
Thera.is no' effective quality control / quality assurance (QC/QA) program in place for start-up testing.
Quality control personnel assigned to the natural circulation test on June 22, 1989, failed to perform their duties.
The QC/QA department appears to have been unprepared for low-power testing and personnel assigned'to that testing were unqualified and untrained.
No recent training was made available to the QC
- personnel prior to testing.
The training made available to operations, engineering and QC/QA personnel in September and October 1988 was not repeated before the June 1989 testing.
Staff IR 88-12 at 4-5 identified two concerns regarding the L
QC/QA departments
- responsibilities: vis-a-vis start-up testing:
1).the QA department had not formulated plans for providing an
. oversight review of the test program and 2) the QC personnel
'did not appear' qualified or capable of performing "an adequate technical review and monitoring function of some of the more complicated low-power physics tests."
Additional training was l l
offered to these personnel in September 1988 but not reoffered.
As a consequence, the QC inspectors assigned to monitor the low-power tests in June 1989 were not technically qualified.
B.
The Start-up Test 1-ST-22 pre-test briefings were not conducted as' required in that Test Step 3.2 which required all personnel involved with procedure performance to lua briefed was not followed.
One of the two control board operators and the shift supervisor (SS) were not briefed.
(AIT at 5.1.3, 5.2.4)
(The AIT is. incorporated herein in full.)
THe briefings that were conducted were abbreviated and fragmented and'not given to the. operators as a group.
(. AIT at 5.2.4, 5.2.6).
These briefings were not effective in communicating needed information to the relevant personnel.
(AIT at 5.1.5 (shift supervisor was not aware of the complexity of the test); 5.1.5 (operators did not trip reactor when trip level was exceeded)).
In fact, the
~
Test Director briefed the management observers and non-participating operators immediately prior to the test, but this briefing was also not effective in conveying either the substance or the importance of the test criteria, because none of these individuals suggested manual trip during the test.
AIT at 5.1.3.
In fact, not one of these seven managers present, including the VP-NP, the Operations Manager, the Assistant Operations Manager, the Station Manager and the Assistant Station Manager prior to the test knew the trip criterion and of these seven only the Station Manager knew there even was such a test trip criterion.
AIT at 5.3.3, 5.3.1. ______-____-_-__a
C.
The Start-up Test Group'(STG)'was not adequately trained and qualified to perform its duties during the start-up test program.
The STG has overall responsibility for the grL
' initial: start-up testing program.
During the Natural Circulation. Test, the Start-up Supervisor was the Acting Shift Test Director.
The Start-up Manager, to whom the. start-up Supervisor reports, the Start-up Supervisor-and the Test.
Director (TD) were in the control room.
AIT at 5.2.1.
The Test Director performs all required briefings for each test and he.has the responsibility for verifying that all individuals involved are briefed as a prerequisite to each test procedure.
Inspection Report 88-15 at 8.
In fact, the Test Director represented that all relevant individuals had been briefed when he initialed the test procedure a few hours prior to the tests.
AIT at 5.2.4.
'In fact, the SS had not been briefed nor-had one of'the control board operators.
AIT at 5.1.3, 5.2.4.
The crew had also not been briefed pre-shift as a group.
AIT at 5.2.4.
In IR 88-13 at 22 the staff noted a concern that a test director was not qualified pursuant.to the requirements of the FSAR.
The Start-up Manager and the Acting Shift Test Director both had authority to terminate the test if plant conditions are not as specified in the test procedures.
AIT at 5. 2 '. l.
Neither of these individuals took any steps to terminate the Natural Circulation Test after pressurizer level dropped below the manual trip level.
AIT at 5.2.1. No classroom training was offered the Test Director or the Acting Shit.'t Test Director on transients that might occur during start-up testing. _ - - - - __ _ _ - _ _ -
AIT at 5.2.3.
Although the Acting' Shift Test Director and the
. Test Director met the training requirements for their respective positions as described at $5.2 of the Start-up Test program
)
Description, Rev. 2, AIT at 5.2.3, this training was simply not adequate to enable the start-up personnel to function i
i effectively to coordinate and direct test activity.
No members of the Start-up Organization are operator license holders, AIT at.5.2.3, and presumably this may have resulted in the failure
.of any intervention by the start-up personnel during testing.
The Start-up' Manager, who was in the control room but-not in
.the operating area, became. aware that the 17% trip criteria had been exceeded when an NRC inspector told him the criteria had been exceeded.
AIT at 5.2.5.
Although the Start-up Manager appeared to hear the inspector's statements he:
continued to watch the in-progress test, appeared.
'to take no action, and gave no oral response AIT, Appendix F at 2.
The Test Director, who was the only member of the start-up staff inside the operating area, became aware that the trip criterion was exceeded when the control board operator announced that letdown had isolated.
AIT at 5.2.5.
Instead of recommending'to the USS that the reactor be tripped, the Test Director instead indicated to the USS that he would begin monitoring computer trends for Tavg to ensure that the 15-minute Technical Specification on Lo-Tavg was not violated.
By performing this task the Test Director removed himself from a position in which he could perform his oversight duties.
AIT at 5.2.5.
Moreover, the USS at the time that the -
t.
trip criterion was exceeded told the.TD that one of "your limit [s]" was exceeded.
AIT at 5.~1.4.
The TD took no steps to correct,the USS's misinterpretation of the very nature of'the test limits.
Shortly thereafter, an NRC inspector told the.TD that the reactor was being operated below the level' requiring a manual-trip.
The TD then communicated to the USS that the NRC had a problem with continued operation below the trip criterion.
Upon being. told by the USS that the problem was being handled, the TD returned to his monitoring of the Tavg and did not recommend that the reactor be tripped.
AIT at 5.2.5.
- Finally, the Acting Shift Test Director who wastaware of the trip
-criterion and that it had been exceeded apparently focussed on analyzing the transient and failed to perform any advisory role at all.
AIT at 5.2.5.
In short, the Start-up personnel whose responsibility it was to coordinate and direct test activities and who were able to either stop the test (Start-up Manager, Acting: Shift Test Director) or recommend stopping the test (TD) totally abdicated their responsibilities.
In IR 88-13 at 23 the. staff noted that changes had been made in the Startup progrem Description manual.
These licensee changes sought to
. provide the Startup Group with "more detailed clarification and direction during the performance of tests that do not go as planned" including guidance for the " interruption of tests."
The Startup Group did not evidence any capacities in this regard.
In essence, there was no one performing the test coordination and direction function. 4
D.
The inadequacy of Applicants' start-up readiness is also clear from an examination of the operational errors that occurred during low-power testing.
Operators did not follow test operating procedures in failing to manually trip the reactri after the pressurizer level dropped below 17%.
The USS did not correlate the isolation of letdown with the loss of l
pressure control and the need to trip the reactor in accordance with the 17% criterion.
AIT at 2.1.
At 17% Jcidown is automatically isolated and pressurizer heaters are deenergized.
Id.
After the malfunctioning steam dump valve was closed, an increasing reactor coolant prepsure transient was developing and primary plant pressure was rapidly increasing.
Id.
The USS had lost pressure control after the automatic isolation of letdown and the deenergizing of the pressurizer heaters.
Id.
Although there were no safety systems or safety functions bypassed for this test, the plant was being operated under special test conditions which allowed the reactor to be critical at power without the reactor coolant pumps operating.
AIT at 4.2.
After the malfunctioning valve was closed and pressure increased, efforts were made to quickly restore pressurizer pressure control by means of auxiliary spray capabilities and letdown.
AIT at 5.1.4.
Neither of these capacities was restored in time to prevent the pressure from rapidly approaching 2340 psig, another test trip criterion.
- AIT, Appendix B at 1-2.
The operators appeared to attach a greater significance to complying with the Technical Specification than the test procedure requirements.
AIT at 5.1.5.
Test procedures.___- __ _
____________N
involve placing the plant in unusual conditions for operation.
i AIT at 6.2.
The natural circulation test is one of the first evolutions performed with a critical reactor.
AIT at 5.1.5.
Test procedures result in operation under an approved margin of safety only if those procedures are strictly followed.
The test procedures are carefully developed and reflect a judgment that these procedures assure plant safety.
AIT at 6.2.
The Applicants reaffirmed the correctness of the 17% manual trip criterion for the natural circulation test after the event.
CAL Response, Enclosure 4, Chronology at 17.
Test conditions call for a heightened sensitivity to test procedures.
AIT at 6.2.
Operating personnel, test group personnel, quality assurance personnel and management personnel all failed to evidence a grasp of the importance of procedural compliance during start-up testing.
This failure is safety significant.
AIT at 6.2.
i l
)
i j
The. Affidavit of July 21 of Gregory C. Minor and Steven C.
Sholly and their-Supplemental Affidavit, filed herewith, are l
incorporated as additional bases for all Intervenor low-power l
contentions:
JI-LP-1; JI-LP-2; and JI-LP-3.
The AIT Report filed herewith is incorporated as additional bases for all Intervenor low-power contentions:
JI-LP-1; JI-LP-2; and JI-LP-3.
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i EXHIBIT 2.
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UNITED STATES NUCLEAR REGULATORY COMMISSION
{
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475 ALLENDALE ROAD 8
KING OF PRUS$1 A, PENN$YLVANIA 19406 i
August 17, 1989 Docket No. 50-443 License No. NPF-67 EA No.-
89-158, Public Service Company of New Hampshire ATTN: Mr. Edward A. Brown, President and Chief Executive Officer New Hampshire Yankee Division Post Office Box 300 Seabrook, New Hampshire 03874 Gentlemen:
Subject:
NRC Region I Augmented Inspection Team (AIT) Inspection (50-443/89-82) of the Natural Circulation Test at Seabrook Station, Unit No.1 This letter refers to the June 28-30, 1989 AIT review of the June 22, 1989 natu-ral circulation test at Seabrook Station, Unit No.1.
The AIT inspection, led by P. W. Eselgroth of this office, was a fact finding and causal factor deter-mination effort.. At the conclusion of the inspection, an exit interview was held with you and members of your staff to discuss the inspection findings.
The AIT report is attached as Enclosure 1.
i Confirmatory Action Letter (CAL) 89-11 stated your agreement to review correc-tive actions and post-trip review results with the NRC staff and to obtain the agreement of the Regional Administrator prior to restart of the unit. You should be prepared to discuss the findings and conclusions of this inspection report and your response to CAL 89-11 at a public meeting planned for Septem-ber 6, 1989 at the New England Center at the University of New Sampshire in Durham, New Hampshire. Following this meeting, elected officials and inter-ested menbers of the public will be offered an opportunity to prctide consnents to the NRC staff on the results of the AIT inspection and on the adequacy of your corrective actions.
If, after review of the enclosed report, you identify additional corrective actions not discussed in your July 12, 1989 response to CAL 89-11, please provide those in writing no later than August 25, 1989.
The expression of concern in Section 5.3.3 of the report for the failure of certain managers observing the natural circulation test to assure adherence to test procedura requirements should not be viewed as establishing new expecta-tions of performance. NRC encourages licensee managers to tour their facilities and observe significant activities and to be alert to conditions that could adversely affect safety.
In general managers, not on watch, shou?d not direct activities of licensed operators but rather should make their concerns known to shift supervision. However, we remain concerned with the lack of action by managers in the control room on June 22, 1989, during the five minutes a test criterion was exceeded, particularly since this condition was identified to licensee management by an NRC representative.
Public Service of New Hampshire, Inc.
2 August 17, 1989 i
The failure to trip the reactor when required and the failure to promptly re-f view and resolve any associated personnel performance implications associated with the failure to trip are potential violations of NRC requirements. To dis-cuss these and other matters identified in Enclosure 2 to this letter, we have scheduled an enforcement conference in the NRC Region I office at 1:00 p.m. on September 7, 1989. At that conference, for each item, please be prepared co present your assessment of safety significance, root cause(s), and your interim and final corrective actions. You will be informed in writing of the NRC deci-sion on enforcement action when that decision is reached after the conference.
In accordance with 10 CFR 2 Appendix C, the enforcement conference will not be open for public observation.
Your cooperation with us is appreciated.
Sincerely,
,fo.T & R I
William T. Russell Regional Administrator
Enclosures:
1.
NRC Region I Augmented Inspection Team Report No. 50-443/89-82 2.
Enforcement Conference Issues and Related Regulatory Requirements cc w/encis:
J. C. Duffett, President and Chief Executive Officer, PSNH T. C. Feigenbaum, Senior Vice President and Chief Operating Officer, NHY J. M. Peschel, Operational Programs Manager, NHY D. E. Moody, Station Manager, NHY P. W. Agnes, Jr., Assistant Secretary of Public Safety, Commonwealth of Massachusetts Public Document Room (PDR)
LocalPublicDocumentRoom(LPDR)
Nuclear Safety Infonnation Center (NSIC)
NRC Resident Inspector State-of New Hampshire Connonwealth of Massachusetts Seabrook Hearing Service List i
l n.
u i
U.S. NUCLEAR REGULATORY COMMISSION REGION I l
Report No.
50-443/89-82 Docket No.
50-443 License No.
NPF-67 Priori ty Category C Licensee: Public Service of New Hampshire New Hamoshire Yankee Division Post Office Box 300 Seabrook, New Hamoshire 03874 Facility Name:
Seabrook Station Unit No. 1 Inspection At: Seabrook, New Hampshire Inspection Conducted: June 28-30, 1989 Inspectors:
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P. W. Eselp4tn, Team t.eader, R1 cate (See attached sheet)
N. F. Ducley, Sr. Resicent Inspector, R1 date (See attached sheet)
L. Lois, Team Memoer, NRR date (See attached sheet)
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J. M. Trapp, Team Member, RI date (See attached sheet)
F. Guentner, Team Member, NRR date Approved:
b_llL4A s a.
7/c23 i
. Wiggi Team Manager, RI date Inspection Summary:
See Executive Summary i
l
_.____1__.___
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U.S. NUCLEAR REGULATORY COMMISSION REGION I Report No.
50-443/89-82 j
Docket No.
50-443 License No. NPF-67 Priority Category C 1.icensee:
Public Service of New Hampshire New Hamoshire Yankee Division L
Fost Office Box 300 Seabrook, New Hamoshire 03874 Facility Name:
Seabrook Station Unit No. 1 Inspection At:
Seabrook, New Hamoshire Inspection Conducted: June 28-30, 1989 Inspectors:
P. W. Eselgroth, Team Leacer, R1 date Oz=L 5 [N>w 7 - N - S f' N._F. Ducley, SentovResident, RI date L. Lois, Team MemDer, NRR date b
~7 6 9 J. p. Trapp, idam Member, RI date F. Guentner, Team Member, NRR date Inspection Summary:
See Executive Summary W
I U.S. NUCLEAR REGULATORY COMMISSION REGION I Report No.
50-4/3/89-82 L
Docket No.
50-443 1
License No.
NPF-67 Priority Category C Licensee: bblic Service of New Hampshire New Hampshire Yankee Division Post Office Box 300 Seabrook; New Hampshire 03874 Facility Name:
Seabrook Station Unit No. 1 Inspection At: Seabrook, New Hampshire Inspection Conducted: June 28-30, 1989 Inspectors:
P. W. Eselgroth, Team Leader, RI date a
N. F. Duciey, Senior Resident, RI date A %s Nf 7 ITfE'1 L. Lois, leam Membar, NRR cate J. M. Trapp, Team Memeer, RI date
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CGuenther, Team Member, NRR date Inspect)on Summary:
See Executive Summary
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'. '. 4 L
l TABLE OF CONTENTS l
Page 1.0. Introduction 5
1.1 Scope of Insp'ection 1.2 Team Composition
- 2. 0 - Executi ve Summa ry..............
5 1
L>
2.1 Event' Summary 2.2 Assessment Summary L
- 3. 0. Event Description...
9 4.0 Plant and Equipment Performance..............
10 4.1 Introduction.
10 4.2 Plant Response....................
10 4.2.1 RCP Trip to Steam Dump Valve liS-PV-3011 Failure-Open 4.2.2 Steam, Dump Valve MS-PV-3011 Failure Open to Closure of All Steam Dump Valves 4.2.3 ' Steam Dump V:1ve Closure to Reactor T.-ip 4.2.4 Summary of Plant Equipment Response 4.3 Steam Dump Valves.....
13 4.3.1 Introduction 4.3.2 MS-PV-3011 Failure to Modulate 4.3.3 Steam Dump Valve History 4.3.4 Valve Failure Cause 4.3.5 Licensee Short-Term Response 4.3.6 Licensee Long-Term Response 1
5.0 Personnel Activities and Performance 15 5.1 C;erating Crew 1
15 v
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TABLE OF CONTENTS Pace 5.1.1 Organization and Responsibilities 5.1.2. Training 5.1.3 Pre-Test Briefing 5.1.4 Crew Response 5.1.5. Performance Assessment 5.2 Startup Test Group.......
22 5.2.1 Organization and Respensibil' fes 5.2.2 Test Procedures 5.2.3 Training 5.2.4 Pre-Test Briefing a
5.2.5 Test Group Response 5.2.6; Performance Assessment 5.3 Management and Support Staff.............
26 5.3.1 Management and Other Support Personnel 5.3.2 Management Responsibilities 5.3.3 Management Response 5.3.4 Performance Assessment 6.0 Safety Assessment..............
29 6.1_ Reactor Safety Significance of Event
.6.2 Safety Significance of Personnel Performance 7.0 Exit Interview............................................
30
.. - =..
J TABLE OF CONTENTS APPENDICES Appencix A:
Chronology of Events Appendix B:
Chronology of Communications Appendix C:
' Individuals Interviewed Appendix D:
Entrance Interview J,ttendees Appendix E:
Exit Interview Attendees Appendix F:
NRC Observations Regarding Seabrook Natural Circulation Test Appendix G:
Augmented Inspection Team (AIT) Charter Appendix H:
Plant and Equipment Perferr.ance Figures Appendix I:
Acronyms and Initialisms l
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1.0 Introduction 1.1 Scope of Inspection In response to the performance of a natural circulation test at the Seabrook Station Unit No.1 in a manner contrary to the test procedure reactor tripping criteria on June 22, 1989, the NRC formed an Augmented Inspertion Team (AIT) to determine the event sequence, causes and safety significance. This was accomplished by establishing a chronology of the event (Appendix A) and accompanying communications (Appendix B), and reviewing equipment performance, plant staff actions relative to this occurrence and applicable station procedures.
The NRC Team held an entrance interview with plant management and support personnel on June 28, 1989 and performed the inspection during the period of June 28-30, 1989. An exit interview was conducted with plant management on June 30, 1989.
Individuals interviewed during the course of the inspection are listed in Appendix C.
Attendees at the entrance and exit interviews are listed in Appendixr.s D and E.
Appendix F contains the statement of NRC observers present curing the June 22nd test. Appendix G is the memorandum of assignment of the AIT to this Seabrook Unit I event.
Appendix H contains plant and equipment performance figures.
1.2 Team Composition
- The team was composed of a team leader and four headquarters and regional specialists with expertise in plant operations, reactor core and plant syst*ms, operator training, test programs and management controls.
2.0 Executive Summary 2.1 Event Summary On June 22, 1989, the plant conducted the natural circulation. test of the primary system which is part of the reactor testing program.
This test gathers primary systen data under controlled conditions to demonstrate the ability of the reteter coolant system to remove decay l
heat using natural circulation.
At the initiation of the test, the reactor was operating at about 2%
power and heat was being removed from the plant by the steam dump valves. Shortly after the point in t0e test where the reactor coolant pumps were turned off to establish natural circulation of the primary system coolant, one of the three controlling group steam cume valves (w5-PV-3011) ealfunctiered and went to the fully ocen position resulting in a rate of Feat removal from the primary system beyone wrat -as planced for the test.
At this time rcre of trE
- recefire
- criteria in the rataral circulation test :-ocedure
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I (1-5T-22) for termination of the test were exceeded nor was the MS-PV-3011 position problem recognized. The presence of this ecuipment problem and the accompanying rate of heat removal resulted in a primary coolant average temperature transient that resulted in l
the coolant level in the pressurizer decreasing towards one of the test's reactor trip criteria at the pressurizer 17% level.
Prior to pressurizer level reaching' the 17% point, the Unit Shift Supervisor (U55), a Senior Reactor Operator, informed the Test I
Director (TD) that one of "your limits" is being approached. When L
pressurizer level reached 17% (at which letdown is automatically isolated and pressurizer heaters are deenergized) the Senior Control Room Operator (SCRO), who is the primary side reactor operator.
l informed the USS of.this, but did not mention the associated reactor 1
trip requirement. At this point the US$ conferred with the TD; steam dump valve MS-pV-3011 had been shut; the pressurizer level decrease had been halted; and, pressurizer level had begun to increase.
It-was on the basis of the pressurizer level recovery taking place that the USS decided to allow the reactor to continue to operate in support of the test. However, the US$ did not correlate the isolation of letdown indication with the less of pressure control and the need to trip the reactor in accorcance with the pressurizer 17% level criterion, a
An increasi.1g reactor coolant pressure transient was now ceveloping due to the closure of the malfunctioning steam dump valve (MS-PV-3011) with the subsecuent recovery of pressurizer level, and j
the US$ directed that the reactor De tripped cue to primary plant
- pressure approachit,g the test procedure trip criterion. Tne shift crew then carried out the emergency operating procedurer for a i
reactor trip and the natural circulation test (2*ST-22) was terminated.
2.2 Assessment Summa y 1
The conclusion of the AIT staff regarding the licensee's response to the plant transient resulting from the malfunction of one of the steam dump valves is that reactor plant safety was never in question, and with the exception of the significant error of not tripping the reactor at the point first called for by the test procedure and loss of pressure control due to letdcwn isolation and pressurizer heater deenergization, the operating staff performed well.
The following summary of assessments is provided with references to f
the sections of the report where further details are documented:
The actual plant dynamic response was reviewed and compared to o
the post trip review precictec response.
The plant respondet as l
predictec in the June 22nc natural circulation testing inclucing i
l the very mild overcooling evert which resultec from steam cutp l
val ve YS-DV-301 's 'ailure to cc:cerly cci. late.
( Section 4.1) 1 l
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Plant equipment was not ready to support the June 22nd test.
o Prior to commencing the test, a test prerequisite to confirm the availability of the steam cump system was signed off.
i However, there was an open work order for post maintenance stroke testing of steam dump valve MS-PV-3011.
(Section 4.3.3) lhe interviews of the Unit Shift Supervisor (USS), Senior o
Control Room Operator (SCRO) and Control Room Operators (CRO)
'found them to be highly competent individuals, clearly aware of their assignments for safe operation of the plant.
In
'l particular, the USS communicated that he had no doubts about being the one responsible for conduct of the test in a safe and 1
controlled manner.
(Section 5.1.1)
Training relative to the conduct of the natural circulation test o
which covered details of the expected plant response had been accotaplished About a year prior to the test. The AIT found no evidence that.such training had been repeated or refresher training given since that time.
(Section 5.1.2)
A review of the pre-test briefing that was conducted for the o
operators by the Test Director determined that it was inadequate with respect to covering the cetails of the testing to be performed and thoroughly reviewing the reactor trip criteria.
(Section 5.1.3)
The operating crew was observed to be conducting plant o
operations in a controlled, unfrenzied manner prior to, during the test and following the reactor trip when the applicable emergency operating procedures were entered and carried out appropriately.
(Section 5.1.4)
During the Low Power Testing program prior to the June 22nd o
event, as well as during this event, there was no evidence of pressure applied by management or anyone else to complete testing at the expense of controlled, safe operation of the plant.
In fact, the NRC has been aware of personnel assigned to shift operating and test responsibilities having received direction from management to proceed with testing in a controlled manner and specifically to not permit themselves to feel rushed into completing evolutions.
(Section 5.1.4)
The US$ did not trip the reactor at the 17% pressurizer level, as o
called for in the test procedure (1-ST-22). He stated his reason was that the decreasing pressurizer level was under control and turning around.
The AIT concluded that a cause of this event was the lack of importance and/or sense of ownership placed on test l
procedure requirements by the USS as compared to his other operat)ng l'
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' requirements such as those contained in Technical specifications and plant operating procedures. Two other operators interviewed also indicated the perception of a hierarchy of importance for orocedural requirements between test procedures and plant operating procedures.
These misunderstandings on the part of the operators. demonstrated an absence of recognition of test procedure criteria as controlling' requirements for operation under testing conditions. (Section 5.1.4)
The Shif t Superititendent (SS) did not provide effective o
supervisory involvement in the conduct of this test. (Section 5.1.5)
From the interviews of operating crew personnel it has been o
concluded that these personnel now recognize and understand that the proper action was to have tripped the reactor before the 1-ST-22 trip criterion on pressurizer level was exceeded.
(Section 5.1.5)
The startup test group had responsibility to interrupt or o
terminate the test in the event that required plant conditions were not maintained. However, no such recommendation was made
.to the shift _ operating crew by the test group even though the Startup Manager was made aware of.the NRC's concern about the plant being below a manual trip criterion.
The overall direction given by the test organization during the performance -
of this test was inadequate.
(Section 5.2.5)
From the interviews of startLp group personnel it has been
- o concluded that these personnel now recognize and understand that the proper action was to have terminated the test and recommend to the operating crew that the reactor be tripped before the 1-5T-22 trip criterion on pressurizer level was exceeded.
(Section 5.2.5)
During the conduct of 1-ST-22 and at the time when plant o
conditions had reached the reactor trip criterion associated with pressurizer level, there were several plant management representatives in the control room with th'e responsibility and authority to terminate test and plant operations when approved i
procedures are not being followed. When members of management I
having specific responsibility and authority relative to safe operation of the plant are present in the control room, their in no way dilutes the responsibilities of the operating presenca crew anc test group personnel assigned to shift.
However, by virtue of the particular responsibilities and authorities that
(
l they do possess relative to safe plant operations, there is a responsibility particularly during unique testing situations -
to keep themselves informed of key limits for operation and plant status re16tive to those limits and to take appropriate action eelative to plant operation whenever others they have
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. assigned to do this have not done so.
This was not done by the management members present.
(Section 5.3.3)
The initial management thrust following this event appeared to o
be to resolve any equipment problems necessary to resume testing. An in-cepth review of the cause or causes leading to the improper conduct of the.1-ST-22 natural circulation test apparently did not take place prior to an initial management decision to resume testing. A thorough review of this event was not completed by the licensee until after the NRC raised this issue with licensee management.
(Section 5.3.3) 3.0 Event Description The following description of the event was determined through observations, interviews with the operators and review of the plant computer traces and printouts. A chronology of the event is presented in Attachment A.
On June 22, 1989, the plant was at about 2% rated power in preparation for the performance of tne natural circulation test, which was intended to demonstrate the ability of the reactor coolant system to remove decay heat using natural circulation. At approximately 12:19 p.m., the reactor coolant pumps were tripped. The loop average temperatures began to increase, as expacted, and the pressurizer level and pressure began to increase. At 12:25 p.m., the steam dump valves began to modulate open and
.one valve failed full open resulting in a rapid cooldown of the primary system.
During the cooldown, pressurizer level dropped below 17% at 12:29 p.m! This caused an automatic iralation of letdown and deenergization of the pressurizer heaters.
The steam dump valve was manually shut at 12:31 p.m. and the coolcown was terminated.
Level in the pressurizer did not go below 14%.
Pressurizer level increased above 17% at 12:34 p.m. and a corresponding pressure overshoot occurred. At 12:35 p.m. the reactor was manually l
tripped due to' primary plant pressure approaching the test procedure trip criteria. The pressure rise was terminated prior to reaching the auto +
matic trip set point due to the manual reactor trip. A reactor coolant pump was started and primary plant temperatures were stabilized at 12:50 i
p.m.
At no time during the transient was a reactor protection or l
engineered safeguards features actuation setpoint reached.
l l
The natural circulation test contains a manual trip criterion which states that the reactor must be tripped if pressurizer level decreases below 17%.
NRC inspectors recognized that a manual trip was not initiated when pressurizer level dropped below 17% and informed the Startup Manager, the Test Director, and the Assistant Operations Manager of the requirement to trip the reactor.
However, no apparent steps were taken to direct the tripping of the reactor prior to the manual reactor trip for increasing prima *y pre 55ure, l
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- i 4.0 Plant and Equipment' Performance I
4.1 Introduction J
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This section covers plant dynamic response including the steam dump f
i valves.
In accordance with the AIT charter the objective is to I
" determine tne expected plant response during a transition to natural j
circulation. cooling and compare it to the actual plant dynamic 1
response observed during the event." In addition " assess the scope and quality of... licensee identified concerns and corrective actions."
Information-was collected through interviews with PSNH employees anc from GETARS (General Electric Transient Analog Recorder System).
This segment of the report is divided into two major parts:
1.
Plant response to an overcooling transient, and 2.
Mechanical and electrical instrumentation aspects of the first steam-dump valve-bank, before, during and after the test.
4,2 Plant Response For this test the reactor was heavily borated at 1150 ppm boren with e
all control rods fully withdrawn except for bank D rods which were positioned at 130 steps out of the core (full out equals 228 steps).
There were no safety systems or safety functions bypassed for this test,however, the plant was being operated under special test
- conditions which allowed the reactor to be critical at power without reactor coolant' pumps operating. All low reactor
- coolant flow trips
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are automatically blocked below the P-7 permissive setpoint (approximately 10*4 power).
There is adequate data collection by the plant's GETARS system computer to reconstruct the vital plant parameter behavior with the i
exception of the valve MS-PV-3011 response.
The reason for the lack of valve MS-pV-3011 data is that a connecting link of the (Bailey) positioner of the valve feedback mechanism had become disconnected which affected both valve operation as well as the computer indica-tions.
For the primary coolant system transient there are three distinct time segments, that is:
1.
From the RCP trip to the steam dump valve opening, 12:18:50 to 12:26:56 (5465 to 5891 see in GETARS indication) 2.
Frem the opening of the steam dump bank to their closing 12:25:56 to 12:31:06 (5891 to 6202 sec in GETARS indication) 3.
Frem the steam dump valve closing to reactor tM o 12:31:06 to 12:35:54 (6202 to 6489 sec in GETARS incicatien)
_ _____---___- _ _-_ - _ a
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, Total transient time 12:35:54 - 12:18:50 = 17 min 4 sec.
The following three report subsections discuss each of the cistinct time sagt:ents in _ detail.
4.2.1 RCP Trip to Steam Dump Valve MS-PV-3011 Failure Open After the RCPs were tripped, the ' otal heat input into the primary coolant system decreased by about 12 MWt, the total heat input from the primary pumps. The reactor was already at about 2.2% power and the steam cump valves were in manual because they were used to dis-pose of the reactor total heat input of about 86 MWt, (i.e., 74 MWt of nuclear heat and 12 MWt of primary pump input). With reactor power at about 2.2% of rated power, Th and Tc loop temperature's showed the initiation of natural circulation with Th rising to about 570*F and Tc dropping to 545'F and Tavg rising by a few degrees in all loops.
(See Figures 1.1 to 1.4, Appendix H).
Pressurizer level and pressurizer pressure increased as the average reactor coolant temperature increased dure to loss of forced circulation, see Figure 2 ( Appendix H).
Steam generator level stayed constant as well as the charging and letdown flows, see Figure 3.
Steam generator pressure began decreasing due to cooldown, see Figure 5.
Decreased primary circulation rate caused coolant and fuel temperature in-creases in the core which in turn decreased core power due to doppler feedback, see Figure 4.
The core configuration for the test i
I (control rod position and boron concentration) were such that the moderator temperature coefficient was about zero thus, dopoler was the only feedback. About 5 minutes into the test, core flow was removing the generated heat, thus Th stopped rising. However, Tc continu.ed falling due to steam dumping.
Therefore, Tavg began to decrease.
Steam generator pressure was also decreasing due to the mismatch between steam dumping level and power and heat production before the RCP trip (at 86 MWt) and af ter the RCP trip (at 74 MWt).
With decreasing reactor power and Tavg, pressurizer pressure and level began to decrease and at 12:24:56 (6 min 6 see into the test) the (condenser) steam dump valve centrol was lost due to the Lo-Lo Tavg interlock at 550*F (P-12).
This occurred because this inter-lock operates on the narrow range Tavg signal which is located on a bypass loop and without forced circulation cools faster than the reactor coolant.
P-12 was bypassed through control room switches and the operator regained steam dump manual control through the first valve bank on the steam pressure mode. As soon as P-12 was bypassed the valves attempted to return to their existing demand position at about 5%. However, MS-PV-3015 was blocked due to a pre existing excessive air leak, valve MS-PV-3011 went open (i.e.,
probably failed to modulate) and only valve MS-PV-3019 operated properly.
Within 40 seccnds valve MS-PV-3019 closed, but MS-Fv-3011 most likely stayed open.
In this brief tirre interval steam cemand increased, charging flow continued to increase and pressuri:er level
.12-continued to decrease. The operator responding to decreasing pres-surizer level, further decreased the letdown flow, see Figures 2, 3, and 5.
As soon as valve MS-PV-3011 closed, steam gene ator level showed a small rapid increase for a few seconds, see Figure 2.
In this first time segment the reactor responded as expected. All major parameters varied in the expected direction and within ex-pected ranges.
Post-event inspection showed that MS-PV-3011 probably failed to modulate.
4.2.2 Steam Dump Valve MS-PV-3011 Failure Open to Closure of All Steam Dump Valves Six seconds after MS-PV-3011 went closed the operator manually be-gan to open the first steam-dump valve-bank to initiate energy dis-posal. The valve-bank valves are supposed to modulate in unison with instruments in manual pressure control.
The control board sig-nals for valves MS-PV-3015 and MS-PV-3019 were correct and as ex-pected.
However, valve MS-PV-3011 went fully open and stayed in that position as was verified a few minutes later by actual obser-v; tion.
As steam dumping continued, pressurizer pressure and level decreased and the operator responded by increasing charging flow, decreasing (to aimost zero) the letdown flow and closing the main steam drains.
In addition Th began to decrease and Tc showed a shar,p downturn, resulting in decreasing Tavg. At this time nuclear power generation shows a slight upturn from a minimum of about 1.4% due to excess heat removal and fuel c.coldown.
Steam generator pressure decreased due to excessive cooldown see Figures 2, 3 and 5.
This plant behasior, that is, excess cooling of the RCS, was caused by valve MS-pV-3011's failure to modulate and being fully open.
The valve failure was established by visual inspection during the transient.
As this trend continued, at 12:28:54 the pressurizer level fell below 17% (which is a procedural reactor trip level),
and, as a result, letdown isolated and pressurizer heaters de-energized, causing the loss of normal pressurizer pressure con-l trol. At this point in time the pressurizer pressure was 2192 I
psia and reached a minimum value of 2179 psia. Pressurizer level i
continued to fall and reachec a minimum of 14.5% at which point l
the operator closed the dump valves. Valves MS-PV-3011 and MS-PV-3019 went fully closed.
In this time period the plant responded as expected in view of the excess cooling of the RCS. Each valve when fully open discharges about 3.3*4 of total steam load, thus, with reactor power at about 1.5% valve MS-PV-3011 fully open and valve MS-PV-3019 partially
{
open the heat loss was at times over 4.0% and the primary system J
heat loss exceeced the heat in:ut from the reactor.
However, valve MS-PV-3011 ' ailed to m:culate and tne operator f ailec to tri; tne i
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. 13 reactor as required. (Note: the valve failure to modulate is discussed in paragraph 4.3.)
4.2 3 Steam Dump Valve Closure to Reactor Trio Within a few seconds of steam dump valve closing, pressurizer pres-sure and level began rising. Charging rate was at 122 gpm (about 1% level / minute) and letdown was isolated.
Likewise, steam gene-rator pressure and level began to rise after a small dip in the level and an upturn in the pressure, see Figures 2, 3 and 5.
Reactor power leveled off at about 2.5%.
As pressurizer level and pressure increased rapidly the operator realized that pressure was getting close to 2340 psia (another procedural trip requirement).
At 12:35:54 the reactor was tripped at a reactor pressure of about 2310 psia and the operators entered emergency operating procedure E-0 in response to a reactor trip. The rise of pressurizer level to 17% was recorded at 12:33:55.
Therefore, the reactor stayed below 17% for about 5 min.
In this time segment, the reactor coolant system responded as would be predicted due to reduced cooling at high chart.ing rate and zero letdown.
4.2.4 Summary of Plant Equipment Response The plant response during operations related to the natural circu--
lation test was as would be predicted, and all plant parameters be-haved normally. A steam cump valve MS-pV-3011 failure to modulate caused an unanticipated cooling of the reactor coolant system. All phenomena were explainable and no unexplained parameter values were observed.
4.3 Steam Dump Valves 4.3.1 Introduction The origin of the primary cooling transient was the malfunction of l
steam dump valve MS-PV-5011, which stuck open and failed to modu-i
$ ate. This section reviews valve performance, operating record, L
failure root cause and licensee short term and long term response.
t Most of the information regarding the valves was obtained from post event examination.
4.3.2 MS-pV-3011 Valve Failure to Modulate Post-event examination revealed that a connecting link nut to &
positioner arm fell off. This mechanism was providing the feedback l
and the disconnected link explains the failure to moculate.
Never-
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theless, valve MS-PV-3011 was able to responc to the final fully-closed signal from the control room.
E.-_____._----------
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. 4.3,3 Steam Dump Valve History Interviews with the system support personnel, cevealed the following with respect to the steam dump valves:
MS-FV-3011 was stroked after the natural circulation test and failed to operate properly due to mechanical binding.
Examination after removal of the valve mechanism revealed that the binding was caused by stem misalignment and interference with a guide bushing.
At the beginning of the preparation for the natural circulation test, valve MS-PV-3011 was not ready to support the test since work order WR87W005592 was still open for a stroke test at NOP/NOT.
In spite of this, a test pre-requisite to confirm the availability of the steam dump system was signed off.
There is no indication as to when the linkage in valve MS-PV-3011 failed.
It had been tested earlier from the control room for closed /open positioning, however, this test would not reveal the linkage problem.
After the June 22nd event, binding was also found in valve MS-PV-3019 but not enough to prevent open/close motion or modulation.
Post-event testing of cli steam dump valves revealed that seven of the twelve valves showed binding, scored stems loose linkage or tight linkage.
In general, the history of steam dump valve system work orders indicates that there is a valve maintenance or design problem.
4.3.4 Valve Failure Cause It is concluded that the MS-PV-3011 steam dump valve failure cause is apparently inadequate valve maintenance or design.
Licensee personnei failed to follow through on a pending wort l
order and failed to recognize and resolve a maintenance problem with the steam durip valves.
In addition the licensee fr.11ed to adhere to test procedures by failing to assure that the required test prerequisites and initial conditions were met before commencing the test.
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N L 4.3.5 Licensee Short-Term Response The following actions were taken or initiated by the licensee while the AIT was on the site:
dismantled the valve MS-PV-3011 mechanism for shop testing called a vendor representative to the site initiated extensive diagnostic testing for all steam dump valves replaced the valve MS-PV-3011 actuator with a new unit'from storage, +.nd performed a comprehensive logic circuit test.
These actions envelope an appropriate review of the behavior of the steam dump valves and constitute a technically sound, prompt and adequate response to the specific valve problem.
4.3.6 Licensee Long-Term Response Licensee personnel expressed their. intent for a complete, det&41ed and in-depth investigation of the valve problem so as to be able to take the appropriate corrective action.
It is the team's understanding that the licensee will investigate:
generic failure rate data base for this type of valve seek to verify whether valve usage (including surveillance testing) is related to failure frequency, and review (and if necessary revise) the current valve maintenance and surveillance program.
These actions 9ppear to be appropriate.
5.0 Personnel Activities and performance 5.1 Ooerating Crew 6.1.1 Organization and Responsibilities Seabrook Station's norma? control room shift crew composition and the crew composition that existed during the day shift on June 22, 1989 were reviewed. Normally, while in mode 2 (startup) operations, the Unit I control room operations staff would consist of a Shift Superintendent (SS), a Unit Shift Supervisor (USS), a Supervisory Control Room Operator (SCRO) and a Control Room Operator (CRO).
Both the SS and the USS possess a senior reactor operator license and the SCR0 and CR0 must be licensed as reactor operators or senior reactor operators.
This is :ensistern with the minimum reovirements for licensed operators per shift for on site staffing of nuclear : wer units
E specified in 10 CFR 50.54 and in the facility's Technical Specifications.
In anticipation ~ of performing the natural circulation test on the morning of June 22, 1989, the normal shift complement was augmented with additional CR0s to assist in performing various control room functions:
one operator was held over from midnight shift to assist in acknowledging secondary alarms; one was assigned to control steam generator level and reactor coolant system temperature; a third operator was assigned responsibility for turbir:e shell and chest warming (he was never used, however); and a fourth additional operator monitored the radiation monitor panels.
This crew augmentation allowed the operators normally assigned to the shift to concentrate on the reactor and the primary plant.
The inspectors reviewed : number of facility licensee docu;nents in an effort to determine the operating shift crew's responsi-bilities during normal operations and upset conditions and daring the startup test program.
Section 2.3 of the Seabrook Operations Management Manual (OPMM) discusses the control room command function and states that the SS is the senior on shift manager and is responsible for the control room command function.
It goes on to state that the SS may, and normally will, delegate this responsibility for each unit to its respective USS.
The SS, under Section 3.3.2 of the OPMM, retains the authority to assume command of the control room, or.to order the shutcown of the reactor when, in his judgement, such action is required to protect the safety of the unit or the health and safety of the public.
Furthermore, the SS is responsible for the safety and operation of the unit equipment, in accordance with approved Station procedures.
Section 1.1 of the OPMM provides' an overview of shift operations and states that the SS maintains a broad perspective of conditions affecting the status and safety of the unit, while the USS maintains a comprehensive perspective of operational conditions affecting the safety of the unit and is in charge of the control room during emergencies.
Section 4.2.4 of the Startup Test Program Description (STPD)
-states that the station staff will perform its normal job func-tions as required to support plant operations and the startup test program. Although the Test Director has the primary responsibility for the execution of the test, the station opera, ting crew has the responsibility for the proper operation of equipment, systems, and the plant and reserves the right to take appropriate corrective actions whenever unsafe or unsatis-factory conditions exist.
A determination by the SS or USS that a test would place the plant in an unacceptable condition is identified in Section 4.3.5 of tne STPD as an event which constitutes ; Ounds f0r a test interruption.
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L l Section 1.5 of the Seabrook Station Management Manual (SSMM) i addresses the issue of procedural adherence and states that where a paocedure exists, it shall be considered guidance regarding the method of performing a function.
Procedures shall be followed, but not without question.
If a procedure directs an action contrary to what is considered proper, the operator should question the procedure and seek resolution with appro-priate supervisory personnel.
It states, however, that a procedure being questioned should not be deviated from on the basis that it is being questioned.
5.1.2 Training The inspection team reviewed the operators' startup test program 7
training completed in preparation for low power testing and other aspects of the licensed operator training program which may have had a bearing on this event.
During the period from April 14 to May 23,1986, the facility's plant reference simulator was used to train all the operators on the tests that would be run during the startup program. The SS, USS and the two CR0s having primary plant responsibility during the natural circulation test were verified as having completed that training. Additional classroom training on the low power test program was conducted as part of the licensed operator requalification training prograin during the period from September 12 to October 21, 1988.
This course was observed by an NRC inspector and was addressed in In:pection Report 88-13.
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The four-hour course, which was conducted by the Assistant Startup Program Manager, provided a detailed description of the startup testing program. The course topics included program administration, organi:ation, test equipment, and applicable procedures, including 1-ST-22, the Natural Circulation Test.
The training also provided the operators with en awareness of the startup test program structure.
The licensed operator initial and requalification training programs were reviewed to determine whether deficiencies in diagnostic and team training or in command and control and procedural compliance training may have contributed to the event on June 22.
It was determined that these subjects are addressed in clasTroom and simulator training during the initial and requali~/ication training programs. Operations Training Standard Number 3, dated January 1989, states that procedural adherence is required with deviation allowed only after procedure changes have been made or in the case of the emergency response procedures by invoking 10 CFR 50.54(x).
This training standard is enc 0rsed by both the Operations and Training Managers.
Interviews with a Training Department representative indicated that the operators are trained to comply with all approved station procedures, regarc'ess of wrether they are operations
-_--.__----2._._.
- 2. - - -...
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e p procedures, administrative procedures or test procedures. The CR0s are instructed to advise the USS when anc if reactor trip criteria are approached and/or exceeded and te trip the reactor unless directed otherwise by the USS.
5.1.3 pre-Test Briefing The licensee's requirements for operating crew briefings were reviewed to determine whether those conducted in preparation for the natural circulation test were adequate.
Section 1.8 of the OPMM addresses shift evolution briefings and states that they shall be conducted for individuals involved in the performance of the evolution.
The detail of the briefing depends on the complexity, logistics or number of people involved in the evolution.
Evolutions involving many individuals, especially from two or more departments or disciplines, may' require large formal briefings or planning sessions.
It goes on to state that l
complex evolutions requiring close coordination of individuals
.should include the following five elements:
review of the appropriate section of the procedure by key individuals; examination of each ine'ividual's specific involvement and responsibility; ciscussion of expected results or performance; review of precautions, limitations, emergency actions to be taken if contingencies arise; and assurance that everyone understands the required interface and communications required.
The insoection team interviewed the operators involved with the conduct of the Natural Circulation Test,1-ST-22, on June 22
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1989, and it was determined that the operators were not briefed as a crew prior to commencing the test procedu*e.
The operating-crew members were individually briefed by the Test Director (TO) curing the early hours of their shift. Copies of the procedure had been distributed to the operators the preceding day but not all the operatcrs had taken the time to review it in detail; the USS reviewed the procedure on the morning of June 22nd.
The primary plant CR0s were given copies of the manual reactor trip criteria, Attachment 9.3 of the test, just prior to commencing i
the test. One of the CR0s and the SS never re:eived an individual briefing. The SS did, however, read the procedure three days before the test was attempted, but ne did not have a copy available to him at the time it was being performed.
Immediately prior to commencing the test, the TD provided a general overview briefing of the test objectives and procedure geared for the management observers and operators from other crews present in the back of the control room.
This briefing provided a-brief overview of the test and wac not directed to the operators performing the test.
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Discussions with NRC inspectors who were present during earlier phases of the low power testing program indicated that the pre-test briefings for the natural circulatier test were less thorough than others had been; previous tests rad also generally included some sort of pre-shift group briefing rather than relying solely on individual briefings.
The SS did not find out until af ter the test was aborted that the operators in his crew had not been properly briefed, and the USS indicated during his interview that while other pre-test briefings have been short, they have generally been more thorough than what was done for the natural circulation test.
5.1.4 Crew Response A detailed description of the event is provided in Section 4.0 of this inspection report and a chronology of significant events is provided in Appendix A.
A chronology of communica-tions during the event is provided in Appendix B.
It became evident during the operator interviews that the primary CR0s and the USS were aware that pressurizer level was cecreasing and approaching the 17% manual reactor trip criterion specified in Attachment 9.3 to 1-ST-22.
The SS, not being as familiar with the test trip criteria as the rest of the operating crew and not having a copy of the procedure to which he could refer, suspected that level had decreased to less than or equal to 17% when he heard letdown isolate, but he did not associate the letdown isolation with a manual trip requirement.
The primary CRCs and the USS were aware that letdown had isolated at 17% pressurizer level and that the manual reactor trip criterion had been satisfied.
The question of why the operators cid not prom;tly trip the j
reactor when they realized that pressurizer level had decreased below the 17% trip criterion was pursued by the inspection team in the interviews.
The prin:ary CR0s knew that the USS was aware of tne level control problems and that he was also aware, as they were, of the requirement to manually trip the reactor.
However, the CRos never actually recommended to the USS that I
the reactor be tripped.
Interviews with the CR0s indicated that they were generally aware of discussions taking place between the USS and the Test Director (TD) rega-ding the loss of pressurizer level. The USS informed the TD that pressurizer level had decreased below "your limit."
In the interim, the USS directed the primary CR0s to monitor level and to report when it reached 15%. At about this time the control room received a report from an operator in the plant that one of the condenser steam dump valves had failed ful' open. The valve was promptly closed, terminating the cooldown t*ansient and reversing the pressurizer level decrease at a;;*wimately 14.5%.
50tn level anc ;ressu e ::e;an to recove- :vicCj a' er c1: sing
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'the failed epen ~ steam dump valve,' and the operators quickly L
tried-to restore pressurizer pressure control capability.
Without pressurizer _ spray or _ letdown capability, pressure rapidly increased past 2300 psig and was approaching the high pressure reactor trip setpoint of 2385 psig. Realizing that pressure was continuing to rise, the USS directed that the reactor be manually tripped.
The total elapsed time from the point when pressurizer' level' decreased below 17% until the operators manually tripped the, reactor was approximately five minutes.
It was apparent from the operator interviews that there was no L
doubt in their minds that the command and controlf function in the control room: rested with the USS and not with the TD..The-USS' informed the TD that level was at 17% and decreasing but -
he f ailed to recognize that the test procedure 17% pressurizer level trip criterion required him to direct shutdown of the reactor at.this point without further discussion or deliberation.
During his~ interview, the USS indicated that he did not. trip the reactor because other-operating procedures do not require a trip until' a lower pressurizer level. Since pressurizer level appeared to be stabilizing as it passed through 17%, he made the decision not to insert a manual reactor trip at that time..It b
was only af ter the' steam dump valve was closed and pressurizer pressure began to rapidly increase toward the automatic trip _
setpoint that'the USS decided that recovery from the transient was not ' feasible and a manual trip was necessary.
The NRC inspectors who were present during the natural circula-tion test witnessed the crew's response to the reactor trip and their performance of the eme'rgency operating procedures.
No
' performance deficiencies were noted during this post trip response.
Through observations and interviews the inspectors determined the Emergency Operating Procedures (EOPs) were adequately implemented folicwing the manual reactor trip.. The Emergency Operating Procedures are normally implemented with two operators -
at the control panel, however during the natural circulation test there were four operators at the control panel.
No prior discussion had been held by the USS as to how the operators were to implement the E0Ps. At the inception of E0p implementation the operator's recognized the need to adjust to the situation and reached an unspoken agreement that only two of the four operators would condu:t the E0P procedure. As a result one of the additional operators who was designated as the Shift Technical Advisor (STA) performed the E0P control board manipulations.
If the E0P recovery had been extended, the inspectors were uncertain whether this operate would have been free to perform his STA responsibilities.
Forty-five minutes after the manual trip tne NRC was notified in accordance with
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the four hour reporting requirement.
.)
5.1.5 Performance Assessment w
The operating crew did not com' ly with an explicit procedural f
p requirement to manually trip the reactor even though they were fully aware that the established trip criterion had been I
exceeded. The CRos should have recommended to the USS that ths-E reactor.be tripped before level exceeded the 17% pressurizer level criterion.
The operator interviews revealed an. apparent tendency by some of them to. place higher priority on satisfying some procedural requirements than others. Some of the operators had atteched a greater safety significance and importance to complying with a Technical Specification.or emergency operating procedure requirement than, for instance, a test procedure.
requirement.
Subsequent to arriving at this conclusion from the operator interviews, the team viewed a video tape of.the June.22nd natural circulation test in which the USS, when discussing the pressurizer level problem with the TD, referred to the 17% pressurizer level reactor trip criterion as "your limit". The USS apparently felt comfortable that the situation was under control since he had not yet approached a lower level trip criterion established in the emergency operating pro-cedures. This hierarchical approach to procedural compliance is not endorsed by the facility's-administrative policies nor by the operators' licensing and continuing training programs.
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The pretest briefing conducted for 1-ST-22 appears to have been inadequate in that the. operators were never formally briefed as a group to address the'five elements' identified in Seabrook Station's OPMM.
All complex evolutions, particularly those involving new or infrequently performed tasks, should be thoroughly briefed. The fact that.the natural circulation test simulator training had been performed over three years earlier and the classroom training was almost a year old should have provided added incentive to ensure that the operators receive some refresher training and were thoroughly briefed prior to commencing the test. The fact that the operators on shift that morning had not routinely worked together as a crew should have emphasized the need to examine, during the pretest briefing, each operator's specific involvement and responsibility and understanding of the required interfaces and communications.
These observations and the assignment of the STA function to a 4
panel operator, discussed in the previous section, indicate the need for more thorough planning and preparation to have been done prior to this test.
Although the SS normally serves an oversight function in the control room, his level of awareness, knowledge and involvement of shif t evolutions was not commensurate with tne significance i
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and complexity of this test.
The fact that the natural circu--
'lation test is one of the first evolutions performed with a critical reactor and the fact that the test' involves abnorsal operating conditions should have been sufficient to raise the SS's level of awareness and involvement, f
NOTE: The vides taping referenced above was done by the licensee for-use by the training department in future training sessions. The inspection team found the video tape to be supportive of the information obtained from the interviews and the resultant conclusions.
5.2 Startuo Test Group 5.2.1 Organization and Responsibi11 ties The organization and responsibilities of the startup staff are delineated in the Startup Test Program Description (STPD), Rev.
2.
The' Startup organization is led by the Startup Manager. The Startup Manager has the overall responsibility for the initial startup program and reports 'to the Station Manager. The Startup Supervisor reports to the Startup Manager. The Startup Supervisor is responsible for detailed coordination of the startup test program.
Reporting to' the Startup Supervisor are the Shift Test Directors.
The Shift Test Director's responsibilities include in part to insure required test' conditions are established in a safe and prudent' manner, and maintained as necessary for test performance.
The startup staff normally present in the control room during startup test performance are the Shift Test Director and the Test Director.
.The Test Director reports to the Shift Test Director and is responsible to perform individual startup tests.
At the time of the Natural Circulation Test Performance, the Startup Supervisor was the Acting Shift Test Director.
During the performance of the Natural Circulation Startup
'.Te s t, 1-ST-22, the Startup Manager, Shift' Test Director, and Test Director were all present in the Control Room.
The responsibilities of the Startup Staff and the Station Operating crew for specific activities are provided in Table 1-1 of the Startup Test Program Description. Test coordination and direction activity is designated as being the responsibility of the Startup Test Department.
The responsibility for systems and equipmer..,erations is delegated to the Station Operating crew.
Section 4.3.5 of the Startup Test Program Description states that the Startup Supervisor or the Shift Test Director will determine if a startup test should be interrupted.
An example of events which may warrant a test interruption provided in the Test program Description is the inability to maintain plant I
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conditions as specified in the startup test.
Section 4.3.6 of the Startup Test Program. Description states that the Startup Manager, Startup Supervisor, or Shift Test Director will
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determine if a test will be terminated. An example of a test g*
termination event is if the performance of a test procedure reveals design or equipment' deficiencies which prevent the objectives and/or acceptance criteria from being met. During the natural circulation test, a plant condition (pressurizer level greater than 17%) was not maintained due to the steam dump
, valve problem which prevented test objectives from being met.
However, no interruption or termination action was taken by the Test Organization.
5.2.2 Test procedyres Methods to change Startup Test Procedures are described in the Startup Test Program Description. Test procedure changes may be.
made utilizing two methods.
For major changes, a procedure revision is required. Procedure revisions undergo extensive review and comment cycles including review by Westinghouse.
The procedure is recca. mended for approval by the Startup Manager and reviewed by the Station Operations Review Committee (SORC) prior to being approved by the Station Manager; Field procecure changes fall into two categories: intent changes and non-intent changes. Pracedure changes which involve a change of intent must be reviewed and approvec by the Startup Supervisor, 50RC, and the Station Manager prior to being implemented.
Non-intent procedure changes (e.g. editorial changes) must be reviewed and
~
approved by the Startup Supervisor and the thit Shift Supervisor (or another SRO) prior to implementation.
In the event that the Startup Supervisor is unavailable the Shift Test Director may previde this review:and approval. Non-intent changes are reviewed by 50RC within 14 days of implementation.
A review of the Seabrook startup test procedures is documented in NRC inspection reports' 50-443/86-31, 86-48 and 88-13.
Each of the inspection reports describes a small number of minor procedure changes which, if incorporated, would more clearly i
or correctly state procedural steps and test objectives.
The applicable changes described in the inspections were incorporated into the startup test procedures prior to 1
implementing the Zero Power' Test Program. The inspections concluded that the startup test procedures werc well prepared and technically sound. Also, the number of test procedure changes made during the test program thus far appears to be less than other comparable facility test programs.
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- 24-5.2.3 Training Training requirements for the Shift Test Director and the Test i.
Director are proviced in the Startup Test Program Description, Rev. 2 Section 5.2, " Personnel Training." The Shift Test Director, and Test Director were provided training in those -
aspects of the program applicable to procedure compliance, test performance, and test documentation.
This training was prov'ded to students as a formal classroom lecture.
In addition, the Shift Test Directors and Test Directors were also provided training on selected transients which might be expected as abnormal occurrences during various startup tests.
This training covered general transient conditions which could occur and did not explicitly cover cooldown transients during natural circulation.
The transient training was provided on a self study basis, without formal training hendouts or lesson plans, with an examination given at the end of the self study period.
Both the Shif t Test Directo-cnd the Test Director met the training requirements described in the Startup Test Program Description.
In addition, both the Shift Test Director and Test Direccor attended an additional course on~ transient analysis which was conducted in the simulator. No members of the Startup Organization are operator license holders at the Seabrook Station, nor are they required to be.
5.2.4 Pre-Test Briefing Procedure 1-ST-22, Rev 2., " Natural Circulation Test," Step 3.2 states that " Personnel involved with the performance of this procedure have been briefed on the procedure content and informed of their respective duties." The Test Director provided information copies of test procedure 1-ST-22 Rev. 2, to the primary desk, the Unit Shift Supervisor's desk, and the Shift Superintendent's desk a few days prior to initiating this -
procedure. The actual execution of the pre-test briefing and sign off of the procedural step occurred a few hours prior to initiating the test by the Test Director speaking with the licensed operators individually on shift. The briefings were very short according to the operators, but did cover the manual trip criteria. The Test Director supplied copies of the manual trip criteria and expected plant response, Attachment 9.3 of 1-ST-22, to the primary operator, reactor controls operator, and Unit Shift Supervisor just prior'to the test.
The control board operators and the Unit Shift Supervisor responsible for shift operation, stated in interviews following this event that they were made aware of the 17% pressurizer level trip criterion during the pre-test briefing with the exception of one of the two control Doard operators assigned to assist the shift crew who stated he was not briefed and was not aware of the manual teip Criteria.
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5.2.5' Test Grouo Response The startup test group crew response was derived from f
observations made by the inspectors during the event and interviews held with the startup group staff following the The Startup personnel present in the control room during event.
the event were the Startup Manager, Shift Test Director, Test Director, and other supporting Startup Engineers.
Of the Startup Staff only the Test Director was positioned inside the operating area, other members of the Startup Group witnessed the test from inside'the control room but outside-the operating area.. Prior to the event the Test Director was communicating test instructions with the operating staff and monitoring test data. Af ter the reactor coolant pumps were tripped, per the test procedure, and the test initiated, the Test Director primarily monitored computer and panel indicatipu.
The Test Director stated that during the event he was aware that the pressurizer level had decreased below the manual reactor trip criteria of 17% when it was. announced by the control board I
operator that letdown had isolated. At this point the Test Director did not recommend to the Unit Shift Supervisor to trip the' reactor.
He indicated to the Unit Shift Supervisor that he would monitor computer trends for Tavg to assure that the 15 minute Technical Specification on Lo-Tavg was not violated.
performing this task essentially removed the Test Director from the overview of plant status.
During the period when pressurizer level was below 17%. an NRC inspector. monitoring the test activities expressed a concern to the Test Diredor
~
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that the pressurizer level was below the manual trip criteria.
Following this communication the Test Director stated that he told the Unit Shift Supervisor that the NRC has a problem with being below the manual trip criterion.
The Test Director stated that the USS said he was handling it.
At no time during this test did the Test Director recommend that the operators manually trip the plant.
The Shift Test Director was monitoring test activities from outside the operating area. The Shift Test Director stated that he was aware of the manual trip criterion for pressurizer level and that the value was exceeded during the test.
He stated that he focused on attempting to analyze the on going transient and, therefore, did not provide an advisory role to the operating staff. At no time during this transient were recommendations provided by the Shift Test Director to the operating staff.
The Startup Manager was monitoring test activities from outside the operating area. The Startup Manager stated that he first became aware of the pressurizer level being below the 17% trip criterion when informec of such by the NRC inspector monitoring startup testing.
The Startup Manager did not communicate the' l
1 m_
. 26-inspector's concerns to the operating crew or other members of the Startup Staff.
5.2.6' performance Assessment The inspection team concluded that the pre-test briefing performed by the Test Director was conducted in a fragmented and abbreviated manner.
Due to the interactions which' occur between plant systems and operator actions, it is important to perform the operator pre-test briefings as a group rather than in a n
piece meal fashion.
Three levels of the Startup organization wert aware that the pressurizer level was below the manual trip criterion during the transient.
Only after the NRC inspector voiced a concern did a startup organization member (Test Director) indicate a concern to the operating staff. At no time during the performance of this test did any member of the startup groJP communicate to the station operating staff a recommendation to interrupt or terminate the test procedure. The technical guidance provided by the startup' organization to the operating staff ciuring this event was inadequate.
In general, the startup organization became more occupied with e
individual tasks at the expense of maintaining at least one individual with overall responsibility for overview and technical input to the Unit Shif t Supervisor for conduct of the test procedure.
5.3 Management and Suecort Staff 5.3.1 Manacement anc Other Support persennel During the performance of the test there were approximately seven managers in the main control room. The Vice President j
of Nuclear production was the most senior manager present.
l i
The Operations Manager and the Assistant Operations Manager were the only managers in the control board area.
i Approximately twenty licensed operators, in addition to the operating crew, were in the main control room to observe the natural circulation test to fulfill the commitment in Final l
Safety Analysis Report (FSAR) request for additional information
(
response. These operators remained outside the control board area,.did not become involved with plant operations and maintained a quiet presence throughout the test.
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5.3.2 Manacement Responsibilities The rescensibilities of the Staticq Yanager and the Assistant Statien Manager, Octh of wnce were present in tne centrcl room l
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. -27 during the test, are delineated in the Nuclear Production Management Manual (NPMM). The Station Manager is responsible for ensuring the station is operated and maintained in accordance with applicable requirements and he serves as chairman of the Station Operation Review Committee (SORC). The i
Station Manager has the authority to direct reactor shutdown I
when conditions may endanger equipment status or the health and safety of the public. The Assistant Station Manager is responsible for maintenance of the programs and procedures needed to operate the station in ar..:,rdance with applicable requirements and he also has the authority to direct the reactor to be shutdown.
The responsibilities for the Operations Manager and the Assistant Operations Manager are delineated in the Operations l
Management Manual (OPMM). The Operations Manager is responsible to direct operating activities in a safe and reliable manner, supervise the Assistant Operation Manager and he is a member of 50RC. He has the authority to order the shutdown of the reactor when action is required to protect the safety of the station or the health and safety of the ptblic. The Assistant Operations Manager has the responsibility for safe operation of the unit's equipment and directs the activities of the members of the operating crews.
He also has the authority to order shutdown of the reactor.
S.3.3 Manacement Response Of the managers interviewed, two were aware., during the test, that pressurizer level had dropped below 17%.
The Station Manager was the only manager interviewed that knew of the existence of a trip criterion on pressurizer level but was unf amiliar with the exact criterion. Most of the staff members interv9swed are members of the 50RC which had reviewed and approved the natural circulation test procedure.
Through interviews with the management staff and review of management responsibilities in the NPMM and the OPMM it was determined that four of the managers interviewed had the authority to direct a reactor shutdown. However, none of these managers communicated to the US$ a need to trip the reactor when pressurizer level decreased below 17%.
The Station Manager stated he was not sure why the USS did not trip the reactor but believed it was due to the training the USS had received in the simulator. The Operations Manager stated 9
that the USS did not trip the reactor because the USS knew the cooldown was causing the pressuri:er level drop and that the USS knew the.Cooldown was under control.
Durir; an interview Concutted on June 2,1959, the Station
- _ _ _ - - - - _ _ _ _ _ i 4
l Manager stated that he recognized soon after the reactor trip on June'22, 1989, that the failure to follow procedures was a significant problem but had been unable to conduct a full discussion of the problem with his management team prior to meeting with.the VP Nuclear Production at approximately 5:00 p.m.
During a conference call on June 22, 1989 with the Region I i
I Branch Chief at 6:00 p.m. the VP Nuclear Production indicated that the procedural compliance issue would be looked at and put in proper perspective and that if tN event occurred again he would expect the operators to trip the reactor.
The VP of Nuclear Production initially indicated a desire to restart the reactor early the next morning but agreed to postpone reactor startup until after a follow-up conference call.
l During the follow-up conference call at 7:30 a.m. on l
June 23, 1989, the licensee outlined the planned modification to their management manuals that would provide additional guidance on the implementation of procedures and outlined the briefings that were planned with all shift crews to present the new guidance. As a result of a subsequent phone call between the Deputy Regional Administrator and the President of New Hampshire Yankee Division a Confirmatory Action Letter was issued requiring that a complete review and analysis of the event be formally prepared and presented to the NRC prior to reactor restart.
Immediately after the phone conversation the license's Event Evaluation Team, the Human Performance Evaluation System team, and the Independent Review Team were assigned to perform separate evaluations of the event.
5.3.4 performance Assessment 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 conduct of the 1-ST-22 natural circulation test i
apparently did not take place prior to an initial management decision to resume testing. An extensive review of this event was not completed by the licensee until after the NRC raised this issue with licensee management.
During the conduct of 1-ST-22 and at the time when plant conditinns had reached the reactor trip criterion associated with pressurizer level, there were several plant management representatives in the control room with the responsibility and authority to terminate the test and plant operations when j
approved precedures are not being followed.
This was not cone.
I Vnen a mem::er of management having specific responsibility and authority relative to safe operation of the plant is present in tre control room, their presence in nc way ::il;,tes tne l
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!l' responsibilities of the operating crew and test group personnel assigned to shift.
However, by virtue of the particular responsibilities and authorities that they do possess relative to safe plant operations, there is a responsibility'-
l' particularly during unique testing situations - to keep them-selves informed of key limits for operation and plant status relative to those limits and to take appropriate. action relative j
to plant operation whenever others they.have assigned to do this have not done so. Plant management present did not do this in the case of the 17% pressurizer level trip criterion that was exceeded.
The reactor was subsequently shut down by the USS when the transient response of another parameter, primary plant pressure, caused the USS to take this action.
6.0 Safety Assessnent 6.3 Reactor Safety Significance of the Event The aspects of this event which cause the plant transient to be different from the Intended natural circulation test transient are the failure of valve MS-PV-3011 to modulate and the fact that the operators did not manually trip the reactor based on pressurizer level. The excess cooling of the reactor coolant system is of little or no reactor plant safety significance in that it is very minor by comparison to other analyzed events (steam line break, inadvertent initiation of a coolant loop, etc.) and these have been analyzed and shown to be acceptable. The June 22nd event is, therefore, totally bounded by these other analyzed events.
6,2 Safety Significance of personnel Performance The failure of the operating crew to trip tne reactor when required by the test procedure during the June 22nd test; the failure of test group personnel to recomn end tripping of the reactor at that point and the failure of management present in the control room to exercise their responsibilities in this situation, despite the fact the plant was being operated under a Technical Specification Special Test Exception, is safety significant. Also, the apparent willingness of management to proceed with testing following the June 22nd occurrence without first completing a thorough review and causal factor assessment is safety significant.
Test procedures often involve placing the plant in unusual conditions for operation, conditions which are not routinely experienced nor necessarily adequately covered by normal operating procedures. Use of test procedures results in operation under an approved margin of safety only when strictly followed.
These test procedures are :arefully developed, utilizing incastry experience ard expertise, are carefully reviewed and cnly approved af ter confidence is establish *ec in their ability t0 assure plant safety.
I*e Concu:t Of tests su:* as tne net' *3' C'* f atiO" test in whien
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As stated in tne previous section, the particular plant transient which resulted from tne combination of the steam dump valve equipment problem and failure te follow the test procedure reactor trip criterion did not significantly challenge the plant margin to safety. However, the operational practice exhibited by the personnel in the control room was unacceptable.
The AIT concluded that all operations, test group and management personnel interviewed now recognize that testing can proceed only if done so in accordance with the test procedure requirements and that if testing should for any reason proceed otherwise the test procedure must first be formally revised. The AIT found no indications of uncertainty or equivocation about this during the site visit.
7.0 Exit Interview On June 30, 1989 a preliminary exit interview was held with licensee management to review the observations and assessments of the AIT. The licensee was informed at the time that this interview might not be the final exit for this inspection. During this inspection, the NRC inspectors received no comments from the licensee that any of their inspection items or issues contained proprietary information.
No written material was provided to the licensee during this inspection.
.On July 5, 1989, the team briefed regional management on the results of the inspection. The licensee was informed by NRC Region I management that the above exit interview would be considerec the final exit.
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l APPENDIX A CHR0h0 LOGY OF EVENTS INSPECTOR TIME:
EVENT:
OBSERVATIONS / ACTIONS:
12:18:00 Pre-RCP trip conditions Pressurizer (PZR) pressure 2237.2 psig. PZR level 25.54%
Wide Range T cold 555.8 F.
All rods withdrawn except bank D (step 133) 12:18:50 RCP breakers are opened All 12 RCS low flow alarms are received 12:25:15 Steam dumps control lost due to permissive P-12 actuation at 550'F Low Tavg 12:25:19 Steam dumps 3019 and 3011 began to open when P-12 was manually bypassed.
All steam dumps in bank should modulate together 12:25:21 Steam dump valve 3011 closes 12:25:21 Steam dump valve 3011 opens 12:25:23 Steam dump valve 3011 closes y
12:25:23 Steam dump valve 3011 opeas 12:25:25 Steam dump valve 3011 closes 12:25:58 Steam dump valve 3019 closes 12:25:59 Steam dump valve 3015 closes 12:26:04 Steam dump valve 3011 fails open 12:28:59 PZR level at 17%
PZR heaters deenergized Letdown isolated 12:30:55' Lowest PZR level 14.5%
Lowest PZR pressure 2179.0 psig l-l Lx_--_-_-_----_-_____-__
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eCHRONOLOGY OF EVENTS INSPECTOR TIME:
EVENT:
OB5ERVATIONS/ ACTIONS:
12:31:06 Steam dump valve 3011 closes 12:32.(about)
NRC inspector discussed need for trip with Startup Manager 12:32:55 Avg. wide range Tavg 539.97'F 12:33 (about)
NRC inspector discussed need for trip with SRI and Deputy Regional Administrator 12:33:55 PZR level 17.95%
12:34 (about)
NRC inspector discussed need for trip with Test Director 12:35:54 Manual reactor trip train A 12:35:54 Reactor trip breakers A and B open 12:35:55 Avg. wide range Tavg 541.90'F l-12:35:55 Highest PZR pressure 2311 psig 12:37:10 PZR heaters restored 1
Key: PZR HI LVL Trip 92%
PZR LO LVL Trip None PZR Heaters and Letdown Isolation 17% PZR LVL l
PZR HI Press Trip 2385 psig PZR LO Press Trip 1945 psig PZR LO Press SI 1865 psig PORV open 2385 psig
^
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APPENDIX B CHRONOLOGY OF COMMUNICATIONS DATE TIME EVENT June 19 Operating crew members provided copies of natural circulation (NC) test procedure.
June 22 09:00 a.m.
Lead Test Director provides trip criteria sheets and individual briefings to Unit Shift Supervisor (USS), Senior Control Room Operator (SCRO), and Control Room Operator (CRO).
21:30 a.m.
Test Director (TD).provides briefing on overview of NC test to main control room.
12:19 p.m.
Reactor Coolant Pumps are tripped.
12:27 p.m.
SCR0 informs USS that pressurizer (PZR) level is falling and going to go below 17%.
USS directs CR0 secondary to secure all steam deasnd. USS Informs TD that PZR Level is going below 17%.
12:29 p.m.
PZR Level below 17%; letdown isolates and P2R heaters ceenergize; Shift Test Director (STD) knows PZR level is below 17% and takes no action.
USS Informs TD that PZR level is below "Your Limit."
USS Directs SCR0 to keep eye on PZR and report when PZR level reaches 15%.
Secondary CR0 believes decision has been reached to continue with test but does not know how decision was reached or communicated to crew.
Shift Superintendent and Operations Manager knew plant was belov 17% PZR level but did not know trip criterion and took no action.
12:31 p.m.
SCR0 and USS discuss PZR level reaching 14.5%.
Phone call to Main Control Room from operator in plant saying steam dump valve was full open.
SCPO reports PZR level increasing.
USS directs SCR0 to restore auxiliary spray capabilities.
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CHRONOLOGY OF CCHMUNICATIONS l
DATE TIME EVENT 22:32 p.m.
NRC Inspector discusses with Startup Manager t
(SM) requirement to trip plant and receives no verbal response. SM observed communications between US$ and TD and takes tio action.
12:33 p.m.
NRC Inspector discusses need for trip with Senior Resident Inspector (SRI) and Deputy Regional Administrator.
12:34 p.m.
TD informs USS that Tavg below required Technical Specification limit.
55 orders 15 minute clock started for Tavg below limit.
NRC Inspector discusses need for trip with TD.
TD approaches USS ar.d provides update on Tavg.
SRI discusses with Assistant Operations Manager need for trip.
Assistr.nt Operations Manager confirms with TD need for trip.
SCR0 reports letdown almost restored.
USS directs SCR0 to watch delta T on PZR spray line.
Assistant Operations Manager approaches 055.
USS directs primary CR0 te manually trip the reactor due to increasing pressure.
SCR0 recuests additional time to establish Auxiliary Spray, 12:36 p.m.
USS directs trip.
Recctor is tripped.
Assistant Operations Manager informs Operations Manager of requirement to trip.
12:45 p.m.
Deputy Regional Administrator informs VP Nuclear Production that NRC has concern with operator's failure to follow procedures.
1:00 p.m.
Licensee management meeting sets schedule for restart as morning of June 23.
1:20 p.m.
SS notifies NRC Operations Center of manual reactor trip.
2:00 p.m.
The licensee's Incident Investigation Team, post Trip Review Team anc Self-Assessment Team Were Established.
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~DATE TIME EVENT 3:30 p.m.
Post Trip Review Meeting was held and dealt-with equipment and procedural issues.
4:30 p.m.
Station Manager and Assistant Station Manager began to discuss the procedura1' compliance
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problem when they were called into meeting with Vice President (VP) Nuclear Production.
6:00 p.m.
Conference Call Between VP Nuclear Production and NRC Regional Branch Chief. Agreement reached to celay startup at least until 7:30 a.m. June 23.
June 23 7:30 a.m.
Conference Call Between VP Nuclear Production and NRC Regional Branch Chief. Agreement reached to delay startup until return call from NRC.
12:00 p.m.
Discussion between Deputy Regional Administrator and President of New Hampshire Yankee resulted-in issuance of Confirmatory Action Letter.
3:50 p.m.
Event Evaluation Team, Human Performance
~
Evaluation System and Independent Review Team established.
1 3
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APPENDIX C.
INDIVIDUALS INTERVIEWED The following is a list of the individuals interviewed, by title, and a summary of their responsibilities during the natural circulation test.
TITLE ROLE OR RESPONSIBILITY Control Room Operator (CRO)
Responsible for Rod Control Panel, Red Control Panel Shift Technical Adviser Primary Board Operator. During E0Ps responsible for tripping reactor when automatic trip setpoint is exceeded.
Assistant Station Manager Observer who has authority to direct reactor shutdown.
Senior Control Rcom Operator (SCRO)
Responsible for PZR, Primary Panel and CVCS.
Responsible for tripping reactor when automatic trip setpoint is exceeded.
Test Director (TO)
Responsible for performance of individual Startup Test.
Operationt Mana0er Observer / Management oversite; has authority to direct reactor shutdown.
CR0 Responsible for cssisting CR0 on Balance of Plant Panels secondary panels. Responsible for trieping reactor when automatic trip sttpoint is exceeded.
I Startup Manager Observer / Supervisory oversite; overall-responsibility for the Initial Startup Program.
CR0 Responsible for Steam Gereraer l
Seconcary Panel Feedwater anc Steam Dumps.
l l
Licensec Operator Responsible for acknowledging Alarms en l
Radiation Monitor Status Panel.
Shift Superintendent Provides requisite technical experti'se to the Unit Shift Supervisor in the event of any abnormal operational occurrence. Authority to order shutcown of reactor.
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TITLE ROLE OR RESPONSIBILITY l-Production Services Manager Observer for Self ' Assessment Team.
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Station Manager Observer has authority to direct reactor shutdown.
l Assistant Operations Manager Observer; has authority to order
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reactor shutdown.
CR0 Acknowledge alarms on Reactor Coolant Turbine Generator Chest Warming Pump trip.
Shift Test Director Coordinate overall plant operations Reactor Startup Supervisor to insure required test conditions are maintained in a safe and prudent manner.
Vice President Nuclear Production Observer.
Manager Operational Support Observer.
Unit Shift Supervisor (USS)
Responsible for conducting operation with approved procedures.
Has auti.crity to order reactor shutdown.
Senior Simulator Instructor Video tape plant response for future training.
OTKER INDIVIDUALS }NTERVIEWED 4
Assistant Startup Manager System Support Department Manager Lead Engineer (I&C) 1 Engineer (I&C)
Engineer Operational Progrsxs Manager 2
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K!NQ oF PRUS$lA. PENNSYLVANIA 194M June 26, 1989 I
MEMORANDUM FOR:
William T. Russell, Regional Administrator TROM:
Thomas T. Martin, Deputy Regional Administrator 1
SUBJECT:
NRC OBSERVATIONS REGARDING SEABROOK NATURAL l
CIRCUI.ATION TEST As requested, please find enclosed a composite narrative of NRC observations regarding the licensee's preparation for and conduct of the Seabrook Natural Circulation Test.
The narrative was developed as a joint effort of Noel Dudley, Senior Resident Inspector, Jim Trapp, Reactor Engineer and myself.
lm-Thomas T. Martin Deputy Regional Administrator Enc 1cnute:
As Stated ec:
J. Taylor, DEDO T. Nurley, NRR J. Wiggins, RI D. Haver) amp, RI N. Dudley, RI J. Trapp, RI n_.,-___.
ENCLOSURE NRC OBSERVATIONS REGARDING SEhBROOK NATURAL CIRCULATION TEST Tim Martin,. ' Deputy Regional Administrator, Noel Dudley, Senior Resident Inspector (SRI),
and Jim
- Trapp, Reactor
- Engineer, representing the NRC, were present in the Seabrook Control Room on June 22, 1989, to observe the preparations for and conduct of the licensee's natural circulation test.
All three NRC participants had reviewed and discussed the test preendure. Tha shift operating crew in the Control Room consisted of a Shift Superintendent,. Unit
-Shift Superintendent, Senior Control Room Operator and three control Room operators.
With the exception of the licensee's operating
- crew, several operations department managers and several test engineers, all personnel (approximately 40 total) were outside the immediate area of the controls and approximately 25 feet from the control panels.
The observers maintained a minimum noise level throughout the. test preparations and conduct.
In preparation for the test, the Lead Test Engineer (LTE) presented a very general discussion of the test to be conducted.
The LTE stated he would review separately with the operating crew the conditions requiring a
(The SRI believes he subsequently observed this briefing taking place. )
In recognition of the assembled observers' inability to read panel indications, the SRI requested-a description of plant parameters presanted on large CRT's that were observable from outside the operating area.
The operating crew identified the parareters displayed on each CRT to enable the observers to follow the transient.
Preparations for the test and conduct of the o;arating crew appeared to be conservative, cautious, and thorough.
The initial operating conditions, needed to initiate this test, required time to establish, Key operating parameter oscillations required dampening while establishing the initial test conditions.
These oscillations were normal and occurred because many controllers were I
requirnd by the test procedure, to be placed in nanual control.
At this point, there was no basis for any concern in the minds of the,NRC observers.
When the plant was finally stabilized at - 3% power, the Unit shif t supervisor (Uss) announced the test was starting.
Two individuals were utilized to trip the four reactor ecolant pumps nearly simultaneously.- The transient w?.s predicted to last 10-50 minutes and the operaters appeared to conscientiously monitoring their controls.
Neutron flux level was noted to decrease, initiating quiet discussion between Mr. Martin and Mr. Dudley, given the stated test prerequisite to reach a zero moderator temperature coeffici,ent.
)
2 Jim Trapp, was the first NRC observer to detect a problem, noting panel indications of an automatic de-energization of the pressurizer heaters and isolation of letdown.
From previous experiences as ' a licensed individual at another facility, he recalled this occurred at about 184 pressurizer level, just slightly above the 174 level that the test procedure instructed operators to manually tri;p the reactor.
Mr. Trapp. asked a. Senior
,~
Reactor Operator (SRO), who was also an observer and not part of the current shift operating crew, what their isolation setpoint was. He. learned it was 174, the condition under the current test procedure requiring the operators to manually trip the reacter.
Although the plant was not currently in danger, Mr.
Trap Engineer'p immediately went to the Startup Manager at the Test s
table.
.Mr. Trapp advised the manager, who had authority to stop the - test, that the heaters trip and letdown isolates at 17%
l pressurizer level and that they were now operating below the criteria for manually tripping the reactor.
The manager continued to watch the in-progress test, appeared to take no action, and gave no oral response; but did appear to hear Mr.'Trepp's concern.
Mr.,Trapp then went to Mr. Dudley and Mr. Martin, inforning them of his concern that the licensee had met conditions requiring a g
manual' trip, for about two minutes, and the itek of response to that information by the Startup Manager.
This discucsion took aboute thirty seconds.
Pressurizer lavs1, as shown on the Ot?, was now offscale hw and the Senior Control Room Operator (SCRO)
I appeared to be initiating additional sakeup with a corresponding
{
increase in indicatad pressure, showing tha': pressurizer level was being restored.
Mr. Trapp then went over to talk to the Land Test Director (LTD) who had his back to the control console and was reviewing data from a printer.
Mr. Trapp informed the LTD, an individual who could recommend halting the test, that they were operating below the level requiring a manual trip of the reactor. The LTD examined his printout, said something to the effect thrit he veruid get back to him, and turned, walked over to the Unit Shift Supervf ser (USS) and i
[
communicated to that individual.
The USS, an SRO with authority to order a reactor trip, was directing the activities of the operating crew.
The SRI, noting that Mr. Trapp was not getting a satisfactory response, immediately went over to the Assistant operations Manager (ACM), an SRO with authority to stop the test, and advised that the pressurizer level was below 17%, requiring a manual reactor trip.
During this period, the LTD returned to the printer, and the AOM asked was it true they should have tripped the reactor.
When told yes, the AOM vent to the Operations Manager, another SRO with 4
i
3 authority to direct tripping the reactor, and the USS, and appeared to communicate with both individuals.
Subsequently, and without a clear impression of whether the response was or was not prompted by the expressed NRC concern, with pressurizer pressure and level now rapidly increasing and again on the CRT scale, the USS directed a Control Room Operator (CRO) to trip the reactor.
The SCRO, an individual who could independently trip the reactor, indicated he was about to re-establish control and requested a delay.
The USS told him no and the CRC then tripped the reactor.
The:NRC observers then watched the apparent smooth performance of the required Emergency operating Procedures, discussed their perception of why the operators initially failed and subsequently decided to trip the reactor, and discussed the safety significance of what had been observed.
The role of the Shift Superintendent during the avant was not apparent to the NRC observers.
Mr. Martin informed the Vice President (VP) of operations, while still in the Control Room, that the NRC staff was concerned that the operators did not follow their procedures and manually trip the reactor when pressurizer level fell below 174.
The VP acknowledged the concern, indicated they would' review the event and offered no explanation for the operators' actions.
the NRC observers remained in the Control Room until the reactor coolant pumps were restarted and the plant was again stable.
At no time during the event did NRC personnel grac a licensed individual, raise their voices or manipulate the controls. The NRC observers' concern during the entire event was that their was no
)
safety reason for not following the procedure; therefore, it should have been followed.
NRC actions were predicated on their concern, the fact that we were not authorized to order licensed activities and that, in this instance, the reactor war never in danger.
Subsequently, Mr. Trapp and Mr. Dudley were directed by Mr. Martin to observs the post trip reviews to assass licensee performance, i
but not to participate in the licensee's deliberations.
l 1
i l
i l
]
i
__-___________________a
Appendix G
~
'JUN 2 71989 MEMORANDUM FOR:
William F. Kane, Director Division of Reactor Projects FROM:
William T. Russell Regional Administrator SUSUECT:
AUGMENTED INSPECTION TEAM ( AIT) - MANUA L REACTO DURING NATURAL CIRCULATION TEST AT SEAEEOOK You are directed to perform an Augmented Inspection Team (A:T) review of-the causes, safety implications, and associated licensee actions which led to and followed, both immediately and subsequently, the manua" reactor trip that occurred during the natural circulation test at Seabrook Station Unit I on June 22, 1989.
The inspection shall be conducted in accorcance with NRC Manual Chapter 0523, Part III, and additional instructions d n this memorandum DRP is assigned responsibility for the overall conduct of tris inspection.
Wiggins is designated as the Regional Team Manager and Pete-Eselgroth as the Jim onsite Team Leader.
of Reactor Safety and from NRR.The Team will' also include participants from the Divisi OBJECTQE The general objectives of this AIT.are to:
Conduct a timely, thorough, and systematic review nf the circumstances 4.
surrounding the June 22,1929 evenc; l
b.
Collect, ar.alyn, and document a'ei relievant data &nd f actual information to determine the causes, conditions, and circvestances portainicg to the event, including the rt.sponsa to the event by the ope-ations and technical support staffs and by licensee management; Assess th'e safety significance of the event and conrnunicate to Regional c.
management the facts and safety concerns related to the problems identified; and to d.
Evaluate the adequacy of the Itc<tnsee's internal post-trip review of the event.
i n
a l
_________m.__
L --
^
I Memorandum for Willian F. Kane 2
1 i
SCOPE OF THE INSPECTION The AIT response should identify and document the relevant f acts and cetermine s
the probable causes of the event.
It should also critical's examine the licensee's response to the event. The Team Leader will develop and implement
{
a specific, detailed inspection plan addressing this event t.pon his arrival j
onsite.
1 As a minimum, the AIT should:
I Develop a detailed chronology of the event; a.
b.
Determine the root cause(s) of. the event; i
Determine the expected response of the plant durirg a transition to c.
natural circulation cooling and compare it to the actual plant dynamic response observed during the event; d.
Assess the adequacy of the training and briefings provided by the licensee to its staff in preparation for the natural circulation test;-
Assess the adequacy of the responses of the operations and technical e.
support staffs to the eveet; Issess the scope and cuality of the iicensee's internal review of the f.
including its initial (preliminary) and final (detailed) post-trip ever.t.
review; and, ACsess the scope and quality of shcrt-term actfons and gather information g.
related to the long tarm actions intended to prevent recurr.tnce of the event, including internal and external communication /dissenfnation of licensee-identified concerns and corrective actions.
SCHEDULE The AIT shall be dispatched to Seabrook Station se as to arrive and commence the inspection no 1 ster than 9.00 a.m., June 28, 1989. A written report on this inspection will be provided to me withirt 3 weeks of completion of on-site inspection effort.
L_
t Memorandum for William F. Kane' 3
TEAM COMPOSITION The assigned Team' rnembers are as follows:
Regional Team Manager James _Wiggins, RI l
l-Onsite Team Leader Peter Eselgroth, RI Onsite Team Members Noel Dudley Senior Resicent Inspector James Trasp, RI Lambros bis, NRD/SRXB Fred Guenther, NRR/LDLB h
W William T. Russell Regional Administrator CC*
- 5. Collins, DRP B. Seger DRS Team Members
.S e
B e
4 G
.___________m___
_.____.____m__.__
.....m_.
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r-APPENDIX I ACRONYMS AND INITIALISMS AIT Augmented Inspection Team CAL Confirmatory Action' Letter CFR Code of Federal Regulations CR0 Control Room Operator EOP.
Emergency Operating Procedure FSAR Final Safety Analysis Report 1
GETARS Seneral Electric Transient Analog Recorder System I-ST-22 Natural Circulation Special Test MW Megawatts MWt Megawatts thermal NOP Normal Operating Pressure NOT Normal Operating Temperature NPMM Nuclear Production Management Manual OPMM Operations Management Manual PSNH.
Public Service of New Hampshire PZR Pressurizer RCS Reactor Coolant System SCR0 Senior Control Room Operator 50RC Station Operative Review Committee SS Shift Supervisor SSMM Seabrook Station Management Manual STA Shift Technical Advisor STPD Start. Test Program Description (STPD)
Tc Primary Coolant Cold Leg Temperature TD Test Director T
Primary Coolant Hot Leg Temperature g
Tavg Average Primary Coelant Temperature USS Unit Shift Supervisor VP Vice President i
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ENCLOSURE 2 Enforcement Conference Issues and Related Reoulatory Requirements 1
1.
The following activities appear to be contrary to:
10 CFR 50, Appendix B, Criterion V, requiring adherence to appropriate procedures; to 10 CFR 50, Appendix B, Criterion XI requiring adherence to test procedures; to Final Safety Analysis Report (FSAR) Section 14.2 specifying t' at 1) the initial n
startup program be administered in accordance with'an approved startup procedure, and 2) that Startup Test Direction personnel will perform startup test coordination and direction functions; and to Natural Circu-lation Startup Test Procedure 1-ST-22.
a.
During the performance of Startup Test Procedure 1-ST-22 on June 22, 1989, pressurizer level reached the 17% criterion requiring a reactor trip in accordance with Attachment 9.3 to the procedure, and the reactor was not tripped by the operating shif t as required (Report Details 5.1.4,5.1.5).
b.
Startup Test 1-ST-22 prerequisite 3.6.7 confirming the availability of main steam dump valve MS-0V-3011 was signed off despite the valve not being properly ready to support the test because work order WR87W005592, requiring a stroke test at normal operating temperature and pressure, was still open (Report Detail 4.3.3).
The failure of MS-PV-3011 during performance of 1-ST-22 initiated the June 22, 1989, test transient.
c.
Startup Test 1-ST-22 pre-test briefings were not conducted as required, in that the Test Step 3.2 provisions for personnel involved with pro-cedure performance to be briefed on procedure conduct and test per-formance was not accomplished for one of the two control board oper-ators assigned to assist the shift crew (Report Detail 5.2.4).
Fur-ther, the briefings which were conducted were not appropriate because they were conducted for individuals in a fragmented and abbreviated manner and not for the operators as a group (Report Details 5.2.4, 5.2.6), because the shift supervisor's awareness and knowledge was not commensurate with the significance and complexity of the test (Report Detail 5.1.5), and because the operators accepted violation of a test procedure trip requirement (Report Detail 5.1.5).
These conditions were evaluated as contributors to the June 22, 1989 fail-ure to trip the plant as required by Startup Test 1-ST-22.
In addition, inasmuch as simulator training on the startup test program was conducted in April and May of 1986 and classroom training on low power testing was last conducted in September and October of 1988 (Report Details 5.1.2,5.1.5), a lack of recent training was a potential additional contributor to the June 22, 1989 failure to trip the plant as required.
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During performance of Startup Test 1-ST-22 on June 22, 1989, the Startup Manager, Shif t Test Director, and Test Director were present in the control room. No interruption or termination action was in-itiated by the Startup Organization when the 171 pressurizer level reactor trip criterion of Startup Test 1-ST-22 was reached nor was the operating staff counselled by the Startup Organization that a reactor trip was required under the existing conditions (Report De-tails 5.2.5,5.2.6).
2.
The following appear to be contrary to: 10 CFR 50, Appendix B, Criterion XVI which requires that measures be established to assure that conditions adverse to quality be promptly identified and corrected, and to assure that the cause for each significant condition adverse to quality and the corrective action taken be reported to appropriate levels of management; l
and to the FSAR Chapter 13.1.2.2 operating shift management provisions; i
and to the assignment of responsibilities for implementation of those pro-l visions in accordance with the Operations Management Manual.
a.
Subsequent to the June 22, 1989 failure to effect a plant trip during conduct of Startup Test 1-ST-22, licensee management failed to l
promptly resolve associated personnel performance failures (Report I
Detail 5.3.3).
b.
During performance of Startup Test 1-ST-22 on June 22, 1989, managers present in the control room included the Operations Manager, who is responsible for the coeration of the unit's equipment in accordance l
with approved station procedures, and the Assistant Operations Manager, who directs the activities of the shift superintendents. Both of i
I these managers have the authority to order a reactor shutdown and were observing Startup Test 1-ST-22 performance in the control board l
area (Report Detail 5.3.2). Neither of these managers effectively I
implemented his oversight responsibility during the test.
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.4 EXHIBIT 3
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