NG-90-2088, Forwards Summary of Root Cause & Corrective Action Plan Re Operator Requalification Training Program,Per NRC 900713 Confirmatory Action Ltr CAL-RIII-90-13

Forwards Summary of Root Cause & Corrective Action Plan Re Operator Requalification Training Program,Per NRC 900713 Confirmatory Action Ltr CAL-RIII-90-13

ML20059D185
Person / Time
Site:	Duane Arnold
Issue date:	08/25/1990
From:	Mineck D IES UTILITIES INC., (FORMERLY IOWA ELECTRIC LIGHT
To:	Davis A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
References
CAL-RIII-90-13, NG-90-2088, NUDOCS 9009060138
Download: ML20059D185 (9)

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((*  ! Iowa Electric Light and Ibwer Company l

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August 25,. 1990--

NG-90-2088

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Mr. A. Bert 'Da'vis . *

-Regiona1; Administrator-Region :III .. t 4' !!; , ..U.S.ENuclear. Regulatory Commission ,

9 A* O- 799 Roosevelt Road .

J;h Glen Ellyn,;IL 60137 j vw 4 Re: Duane Arnold Energy Center W '

Docket No: 50-331 Op.; License DPR-49

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Reference:

. CAL RIII-90-013  :

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Subject:

Root Cause and Corrective Action Plan-regarding'the' Operator Requalification J, Training-Program '

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O. .w File:-.A-104, A-204t q

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Dear Mr. Davis:

'By letter dated July;13,1990,cthe Nuclear Regulatory Commission.

stransmitted to Iowa: Electric Light and Power Company a Confirmatory

~Actiot Letter concerning the Duane Arnold Energy Center operator requalification' exams (see Reference). The letter requested that we l provide the'results and actions based on the determinations of an I independent. root cause analysis.

J At.tachment_1 contains a: summary and Attachment 2 contains the oot causes-and corrective actions, l

i Very truly yours, 4

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et 1//A i Daniel L. Mineck Manager, Nuclear Divis,on DLM/VJC/p1 p

Attachments: 1) Jummary l> 2) Root Causes and Corrective Actions 906906oise 900825 PDR ADOCK 05o00331 l y PDG Geneml mlice In Itm .ut ce<t.or riaphi.s. Icmu x40s . 3,gnonaart ,

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4 cc: Director of- Nuclear Reactor Regulation -

Document Control Desk

-U.S. Nuclear Regulatory Commission-

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. Wash.1gton, D.C. 20555 , o J NRC Resident Inspector'- DAEC L.=Liu -

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. ATTACHMENT 1 NG-90-2088 3!# MARY f A task force was assembled to investigate the causes of the unsatisfactory examination results in our licensed operator requalification program. This task force consisted of three Iowa Electric employees who collectively have experience in the areas of root cabse analysis, control ect.s operations, and offs'te safety assessment. The Operations Training Supervisor and an Operations I Training Instructor from Northern States Power Monticello Station were '

members of the task force. These outside utility members were added to ahance our independent perspective during the evaluation.

As a result of its investigation, the task force identified three root causes. They deal principally with the limited availability of the simulator for trair;ing, poor communications between the Operations i' and Training Departments, and overconfidence in our abilities. These root causes are described more fully in the attachment along with the corrective actions we are taking to ensure that our training rregram is returned to a satisfactory status.

Between July 11,. 1990 and August 11, 1990 we conducted remedial training-of the three crewt which failed the NRC exam and conducted similar erf.anced training for the three operating crews which were not examined.

The training was designed to address our preliminary root-cause assessment. Following the root-cause task force's investigation, we re-evaluated the remedial / enhanced training and determined that it also addressed the additional issues identified by the task force.

During the week of August 13, the NRC conducted an Operations Evaluation of the operating crews not ;1eviously examined and re-examined the crews which failed the NRC exam. The tested crews performed very well with all six crews being judged satisfactory. This dramatic turn-around in operator performan:e validates our. root cause analysis conclusions and short-term corrective actions.

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. ATTACHMENT 2 ,

i NG-90-2088 i

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ROOT CAUSE: Inadequate time on simulator. l While the examinees correctly answered more than 90% of the questions on the Emergency Operating Proced1res (EOPs) in the written portion of the requalification examination, seven of the sixteen individuals and three of the four crews failed the simulator portion of the examination.on the E0Ps. Thi: demonstrates that while the examinees had a good understanding of the E0Ps they had difficulty in executing them i in a dynamic, real-time environment. ,

We began operation of the DAEC on-site simulator in December 1989. .

Training of Operations personnel on this site-spt:cific simulator stat ted ,

in January 1990. Licensed operators at the DAEC are assigned to training for one week out of each six week period. This constitutes one training cycle. Thus, the operators tested in June 1990 had completed only three cycles of training which included training on the DAEC simulator before the requalification examination. During ,

each cycle, an operator has ap,,roximately II hours of hands-on 8 simulator time; therefore, each candidate had accumulates approximately 33 hours3.819444e-4 days <br />0.00917 hours <br />5.456349e-5 weeks <br />1.25565e-5 months <br /> of simulator experience with E0P:, prior to the examinations.

Little time was deveted to remediating weak simulator performance.

Industry guidelines recommend 60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br /> per year on a plant-specific simulator to develop and maintain acceptable proficiency with E0Ps.

Consequently, lack of time available to practice the E0Ps on the simulator was determined to be a root cause of the training deficiencies. -

Also worth noting, a contributory cause of the failure of certain crews during the simulator portion of the exam was that crew member assignmei.is were changed in April. Consequently, the crews had only 11 hourt of training together, a period insufficient to develop the necessary teamwork to perform well together. Teamwork and communiat%a within crews were also hindered by the lack of a clearly defined task statement for each operating crew member.

CORRECTIVE ACTIONS The time spent on the simulator will be increased. Including the enhanced training, operating crews have received over 60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br /> of hands-on simulator time. The staff crews will have over 60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br /> on the imulator by December 31, 1990. Beginning with tha 1991 requalification cycle the training schedule will provide approximately 80 Surs of simulator time.

Command and control functions will be enhanced by special teamwork training. This training will include instruction in the simulator on command and control. This training will improve the comn ,lications and teamwork among the members of each crew. This training ccm:nenced August 21, 1990 and will be completed by October 31, 1990.

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. ATTACHMENT 2 NG-90-2088 Page Two A remediation process for individuals and crews who do not perform up. to .

standards during the weekly, evaluated E0P scenario in the simulator

• will be developed. Additional simulator time will be utilized if  ;

necessary to bring these individuais and crews to an acceptable '

level. This remediation process will be in place by October 31,l1990.

We will continue to minimize crew changes to the extent possible but i some changes are inevitable because of promotions, i'Inesses, vacations, etc. To make any crew reassignments-less detrimentai to teamwork, we have been addressing crew member roles and teamwork during remedial /

enhanced training. .However, for the long term, we will review and i enhance the defined roles of each crew member. This will ensure that each operator understands what is expected of his position. This will be completed by October 31, 1990.

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. ATTACHMENT 2-NG-90-2088  :

Page Three.

ROOT CAUSE: Lack of effective communications and cooperation i between the Operations Department and the Training Department.

The Operuor Training Program requires that simulator scenarios and I operator performance objectives, i.e., critical tasks, be reviewed by Operations management. The Operations Department oid review the scenarios and Job Perfonnance Measures (JPMs), but ,

the review was not fully effective at identifying potential problems ,

with critical tasks. This permitted the development and teaching of standards for simulator operation which were different from the standard which had been set by Operations to govern operation of the plant itself. As a result of tMs " double standard," disagreeraents and conflicts. arose during simulator training. On occasion instructors advised operators that certain actions taken by them were improper and' ,

the operators insisted that they were correct. In addition, lack of ,

actual DAEC control room experience by many of the Training Instructors contributed to these disagreements, i.e. they lacked specific plant experience and therefore credibility with the operators. Because these disagreement., were not promptly resolved, the authority and  ;

credibility of the instructors were further affected. Thess disagreements between the operators and the training instructors concerning interpretation of the E0Ps (especially "before" statements) continued throughout simulator training. In the requalification examination, the Training Department instructors gave failing grades to operators and crews on the basis of their strict interpretations  ;

of E0Ps which had been_ rejected earlier by the oprators.

CORRECTIyLACTIONS:

A formal procedure will be feveloped to resolve any disputes that arise.

during simulator training. This will ensure that identified concerts are addressed and resolutions are documonted and taught consistently to all the crews. This procedure M be in place by October 31, 1990.

The Operations Department is now performing additional reviews of all accident scenarios and JPM critical tasks used for formal evaluation. These reviews will be completed prior to the use of these scenarios and JPMs.

We will increase Operations Department involvement in the licensed operator training program. There are currently several licensed operators transferring to the licensed operator training program to serve es instructors. Also, individuals from the Operations Department with an Sk0 license will be rotated through the Training Department to help with scenario development and critical task reviews. They will also assist in evaluating performance on the simulator. Training instructors will be assigned to the Operations Department as a part of this rotation. A schedule for this rotation will be established and reported to management by December 31, 1990.

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ATTACHMENT 2 NG-90-2088 Page Four Beginning in October 1990, a member of the relief crew will be  !

utilized ss available to assist in evaluating performance on the simulator. This will encourage the Training Department and the  ;

Operations Department to work together.

The management of the two departments will also participate in

. evaluating performance of a dynamic simulator scenario each training cycle beginning in October 1990.

The above corrective actions will assure that the Operations

. Department and Training Department will work together towards the '

mutual goal of an acceptable training program. ,

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, . ATTACHMENT 2 NG-90-2088 Page Five ROOT CAUSE: Overconfidence of Licensed Operators and  ;

Managers Involved in Training Program.

The Duane Arnold Energy Center operators have had a history of .

performing well during the annual exams. This led the operators, instructors and their supervisors to believe that the candidates would perform well on the new-format NRC exam.

Most operators did not practice the Job Performance Measures (JPMs),

even though the JPMs are readily available. Also very little time e during requalification training was scheduled for practicing these JPMs.

The operators were confident of passing the exam so they did minimal studying.

Management of the Training Center and Operations Department was not aware of the consequences of crew failure on the weekly simulator evaluations. Management agreed that no remedial action was warranted. Verbal feedback on operator performance for simulator evaluations was thought to be sufficient to correct any performance problem. No additional simulator time was scheduled. The need for i additional practice to ensure adequate E0P performance was ,

underestimated.

The use of industry experience was inadequate in that contacts with several other utilities failed to alert the Training Department management to the increased level of simulator performance that would be required in the NRC requalification exam. The accident scenarios which Iowa Electric submitted to the NRC for use in the requalification exam were determined by *he NRC Examiners to lack sufficient complexity to adequately test the operators ability to execute the E0Ps. This occurred only 20 days before the scheduled  :'

exam. Consequently, these scenarios were replaced by scenarios which were much more complicated than those on which the crews had been trained. In addition, the grading standards of the training scenarios has been less stringent than those applied during the exam. Both of these conditions resulted in the practice exams providing the operators and instructors with a false sense of security.

The Training Department had not planned properly for scheduling during the exam week. The large number of people being tested and the une %ected amount of time required to complete testing and critiquing caused long delays. One contributor to this probl~em was incorrect time validations for JPMs. Some people were sequestered more than 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> waiting for their examination on the simulator. Instructors sometimes worked as much as 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br /> a day. Although the effect of the resulting anxiety end fatigue is difficult to quantify, we can conclude that the effect was not a positive one, i

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. . ATTACHMENT 2 ,

NG-90-2088 l Page Six 1 ti CORRECTIVE ACTIONS A policy specifying remedial action to be taken in the event of  :

simulator failures during training will be in place by October 31, 1990. There is already such a policy for failure of the written -

exam. This will ensure an individual repeats a scenario when his I

performance has not been adequate. Additional simulator time will be '

available if needed for remediation. This policy will also ensure that strict pass / fail criteria are applied during the weekly requalification training.

Scheduling during the examination period will be improved to avoid ,

contributing to operator stress. This will be done by assigning an individual to scheduling duties with a view of reducing the time .

5 operators must wait to begin their examinations. The JPMs used during an evaluation will be revalidated for more accurate time -

estimates by December 31, 1990.  :

We will continue to develop additional accident scenarios, which meet NRC standards for complexity, for use in requalification training. This >

will ensure that operators are trained on scenarios that are as i difficult as the scenarios which are encountered on the exam.

t Beginning with tha first training cycle in 1991, after revalidation of JPMs, all sections of the exam will be stressed anf practiced during requalification training. These will include Ms, written exam, static and dynamic simuletor, f

A mock exam will be performed prior to the next exam. This will expose

- the operators to exam-like conditions and will enable us to identify any potential weaknesses in our operators or program prior to the exam. ,

The process by which the Training Department collects industry experience and incorporates it into the various training programs will be enhanced. There enhancements will ensure that available

( industry information is effectively utilized. This will be ccmpleted prior to October 31, 1990.

During the week of August 13, the NRC conducted an Operations Evaluation of the operating crews not previously examined and re-examined the crews which failed the NRC exam. The tested crews performed very well with all six crews being judged satisfactory. This dramatic turn-around in operator performance validates our root cause analysis conclusions and short-term corrective actions, h

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