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{{#Wiki_filter:February 13, | {{#Wiki_filter:February 13, 2007 | ||
Mr. Timothy J. | EA-07-001 | ||
Mr. Timothy J. OConnor | |||
Vice President Nine Mile Point | |||
Nine Mile Point Nuclear Station, LLC | Nine Mile Point Nuclear Station, LLC | ||
P.O. Box 63 | P.O. Box 63 | ||
Lycoming, NY | Lycoming, NY 13093 | ||
PRELIMINARY WHITE FINDING - NINE MILE POINT NUCLEAR | SUBJECT: NRC LICENSED OPERATOR REQUALIFICATION PROGRAM INSPECTION | ||
During the period October 16, 2006 through January 9, 2007, the US Nuclear | REPORT 05000220/2006011 AND 05000410/2006011; | ||
Operator Requalification Program activities. | PRELIMINARY WHITE FINDING - NINE MILE POINT NUCLEAR STATION | ||
Dear Mr. OConnor: | |||
During the period October 16, 2006 through January 9, 2007, the US Nuclear Regulatory | |||
Commission (NRC) conducted an inspection of the Nine Mile Point Nuclear Station Licensed | |||
Operator Requalification Program activities. The enclosed report documents the inspection | |||
findings, which were discussed on January 18, 2007 in an onsite exit meeting with you and | findings, which were discussed on January 18, 2007 in an onsite exit meeting with you and | ||
members of your staff.The inspection examined activities conducted under your license as they relate to safety | members of your staff. | ||
The inspection examined activities conducted under your license as they relate to safety and | |||
compliance with the Commissions rules and regulations and with the conditions of your license. | |||
The inspectors reviewed selected procedures and records, observed activities, and interviewed | The inspectors reviewed selected procedures and records, observed activities, and interviewed | ||
personnel. | personnel. The inspection consisted of a review of the licensed operator requalification | ||
program. | program. Findings identified during the inspection are discussed in detail in the enclosed | ||
inspection report.This report documents a preliminary White finding that appears to have low to moderate | inspection report. | ||
This report documents a preliminary White finding that appears to have low to moderate safety | |||
significance. As described in Section 1.R11 of this report, your Licensed Operator | |||
Requalification Training Program allowed operating crews to validate simulator exam scenarios | Requalification Training Program allowed operating crews to validate simulator exam scenarios | ||
that were substantially the same as those that were later administered to these crews as part of | that were substantially the same as those that were later administered to these crews as part of | ||
their annual operating test. | their annual operating test. This shortcoming had the unintentional effect of compromising | ||
your Unit 1 2005 and 2006 dynamic simulator exam scenarios. | your Unit 1 2005 and 2006 dynamic simulator exam scenarios. The apparent compromise of | ||
the 2005 Unit 1 simulator exam scenarios is considered more serious and the basis for the | the 2005 Unit 1 simulator exam scenarios is considered more serious and the basis for the | ||
preliminary White finding since the apparent compromise was not corrected by Constellation | preliminary White finding since the apparent compromise was not corrected by Constellation | ||
prior to returning licensed operators to normal duties. | prior to returning licensed operators to normal duties. In contrast, for the 2006 exam | ||
compromise problems Constellation took remedial actions by retesting all operators prior to the | compromise problems Constellation took remedial actions by retesting all operators prior to the | ||
end of the exam cycle. | end of the exam cycle. This finding was assessed using the Operator Requalification Human | ||
Performance Significance Determination Process as a potentially safety significant finding that | Performance Significance Determination Process as a potentially safety significant finding that | ||
was preliminarily determined to be White; i.e., a finding with some increased importance to | was preliminarily determined to be White; i.e., a finding with some increased importance to | ||
safety, which may require additional NRC inspection. | safety, which may require additional NRC inspection. The issue has a low to moderate safety | ||
significance because it represented a failure to recognize and correct an apparent examination | significance because it represented a failure to recognize and correct an apparent examination | ||
compromise of the 2005 Unit 1 simulator exam scenarios, and a subsequent return to normal | compromise of the 2005 Unit 1 simulator exam scenarios, and a subsequent return to normal | ||
T. | |||
reasons: (1) there were no significant plant performance issues related | T. OConnor 2 | ||
watch-standing duties by the licensed operators without adequate compensatory actions for the | |||
compromised examinations. This finding was not an immediate safety concern for the following | |||
reasons: (1) there were no significant plant performance issues related to operator knowledge | |||
and abilities; (2) all licensed operators had participated in a continuous requalification training | and abilities; (2) all licensed operators had participated in a continuous requalification training | ||
program; (3) this issue, while pervasive, was limited to the 2005 and 2006 exams and did not | program; (3) this issue, while pervasive, was limited to the 2005 and 2006 exams and did not | ||
Line 54: | Line 67: | ||
invalidating the simulator exam scenario portion of the 2006 annual operating exams and | invalidating the simulator exam scenario portion of the 2006 annual operating exams and | ||
administering new and more comprehensive simulator exam scenarios to all licensed operators | administering new and more comprehensive simulator exam scenarios to all licensed operators | ||
upon discovery of this concern by the NRC. The finding is also an apparent violation of NRC requirements and is being considered | upon discovery of this concern by the NRC. | ||
on the | The finding is also an apparent violation of NRC requirements and is being considered for | ||
escalated enforcement action in accordance with the Enforcement Policy, which can be found | |||
on the NRCs web site at http://www.nrc.gov/reading-rm/adams.html. | |||
Before we make a final decision regarding the preliminary White finding, we are providing you | |||
an opportunity (1) to attend a Regulatory Conference where you can present to the NRC your | |||
perspective on the facts and assumptions the NRC used to arrive at the finding and assess its | perspective on the facts and assumptions the NRC used to arrive at the finding and assess its | ||
significance, or (2) submit your position on the finding to the NRC in writing. | significance, or (2) submit your position on the finding to the NRC in writing. If you request a | ||
Regulatory Conference, it should be held within 30 days of the receipt of this letter and we | Regulatory Conference, it should be held within 30 days of the receipt of this letter and we | ||
encourage you to submit supporting documentation at least one week prior to the conference in | encourage you to submit supporting documentation at least one week prior to the conference in | ||
an effort to make the conference more efficient and effective. | an effort to make the conference more efficient and effective. If a Regulatory Conference is | ||
held, it will be open for public observation. | held, it will be open for public observation. If you decide to submit only a written response, such | ||
submittal should be sent to the NRC within 30 days of the receipt of this letter.Please contact Mr. Marvin Sykes at (610) 337-5046 within 10 business days of the date of | submittal should be sent to the NRC within 30 days of the receipt of this letter. | ||
Please contact Mr. Marvin Sykes at (610) 337-5046 within 10 business days of the date of your | |||
receipt of this letter to notify the NRC of your intentions. If we have not heard from you within | |||
10 days, we will continue with our significance determination and enforcement decision and you | 10 days, we will continue with our significance determination and enforcement decision and you | ||
will be advised by separate correspondence of the results of our deliberations on this matter.Since the NRC has not made a final determination in this matter, no Notice of Violation is | will be advised by separate correspondence of the results of our deliberations on this matter. | ||
Since the NRC has not made a final determination in this matter, no Notice of Violation is being | |||
issued for this inspection preliminary White finding at this time. In addition, please be advised | |||
that the number and characterization of the apparent violation described in the enclosed | that the number and characterization of the apparent violation described in the enclosed | ||
inspection report may change as a result of further NRC review.In addition, the report documents three NRC-identified findings of very low safety significance(Green). | inspection report may change as a result of further NRC review. | ||
requirements involving | In addition, the report documents three NRC-identified findings of very low safety significance | ||
for Unit 1 for reasons detailed in the enclosed report. | (Green). One of these findings was determined to involve a Unit 2 violation of NRC | ||
requirements involving similar but less significant exam compromise issues to those identified | |||
for Unit 1 for reasons detailed in the enclosed report. The unintentional 2006 Unit 2 simulator | |||
exam scenario compromise was assessed separately due to Unit 1 and 2 plant design | exam scenario compromise was assessed separately due to Unit 1 and 2 plant design | ||
differences that require unique training programs for each unit, as well as unique plant and | differences that require unique training programs for each unit, as well as unique plant and | ||
operator licenses. | operator licenses. However, because of the very low safety significance and because it is | ||
entered into your corrective action program, the NRC is treating the Unit 2 exam compromise | entered into your corrective action program, the NRC is treating the Unit 2 exam compromise | ||
finding as a non-cited violation (NCV) consistent with Section VI.A.1 of the NRC Enforcement | finding as a non-cited violation (NCV) consistent with Section VI.A.1 of the NRC Enforcement | ||
Policy. | Policy. If you contest this NCV, you should provide a response within 30 days of the date of | ||
this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, | this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, | ||
ATTN: Document Control Desk, Washington DC 20555-0001; with copies to the Regional | ATTN: Document Control Desk, Washington DC 20555-0001; with copies to the Regional | ||
Administrator, Region I; the Director, Office of Enforcement, United States Nuclear Regulatory | Administrator, Region I; the Director, Office of Enforcement, United States Nuclear Regulatory | ||
Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at Nine Mile Point | Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at Nine Mile Point | ||
Nuclear Station. | Nuclear Station. | ||
T. | |||
http://www.nrc.gov/reading-rm/adams.html | T. OConnor 3 | ||
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its | |||
T. | enclosure will be available electronically for public inspection in the NRC Public Document | ||
Room or from the NRCs document system (ADAMS), accessible from the NRC Web site at | |||
http://www.nrc.gov/reading-rm/adams.html. | |||
Sincerely, | |||
/RA/ | |||
A. Randolph Blough, Director | |||
Division of Reactor Safety | |||
Docket No: 50-220, 50-410 | |||
License No: DPR-63, NPF-69 | |||
Enclosure: Inspection Report 05000220/2006011 and 05000410/2006011 | |||
T. OConnor 4 | |||
cc w/encl: | |||
M. J. Wallace, President, Constellation Generation | |||
M. Heffley, Senior Vice President and Chief Nuclear Officer | |||
C. W. Fleming, Esquire, Senior Counsel, Constellation Energy Group, LLC | C. W. Fleming, Esquire, Senior Counsel, Constellation Energy Group, LLC | ||
M. J. Wetterhahn, Esquire, Winston and Strawn | M. J. Wetterhahn, Esquire, Winston and Strawn | ||
Line 96: | Line 131: | ||
D. Katz, Citizens Awareness Network | D. Katz, Citizens Awareness Network | ||
T. Shortell, Manager, Nuclear Training | T. Shortell, Manager, Nuclear Training | ||
S. Glenn, INPO | S. Glenn, INPO | ||
T. | |||
T. OConnor 5 | |||
Distribution w/encl: | |||
ADAMS (PARS) | |||
SECY | SECY | ||
CA | |||
OEMAIL | OEMAIL | ||
OEWEB | OEWEB | ||
Line 131: | Line 169: | ||
D Holody, RI | D Holody, RI | ||
R Summers, RI | R Summers, RI | ||
C | C ODaniell, RI | ||
J Schlueter, FSME | J Schlueter, FSME | ||
RidsFSMEdmssa | RidsFSMEdmssa | ||
Line 142: | Line 180: | ||
K. Kolek, OA - NMP | K. Kolek, OA - NMP | ||
DRS Master Exam File ©. Bixler (w/concurrences) | DRS Master Exam File ©. Bixler (w/concurrences) | ||
DRS File | DRS File | ||
T. | |||
T. OConnor 6 | |||
" C" = Copy without attachment/enclosure | C:\FileNet\ML070440231.wpd | ||
U.S. NUCLEAR REGULATORY | SUNSI Review Complete: JGC (Reviewers Initials) | ||
License No:DPR-63, NPF-69 | DOCUMENT NAME: C:\FileNet\ML070440231.wpd | ||
Report Nos:05000220/2006011, 05000410/2006011 | After declaring this document An Official Agency Record it will be released to the Public. | ||
Licensee:Nine Mile Point Nuclear Station, LLC (NMPNS) | To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure "E" = Copy | ||
Facility:Nine Mile Point, Units 1 and 2 | with attachment/enclosure "N" = No copy | ||
Location:Lake | OFFICE RI/DRS RI/DRS RI/DRS RI/ORA RI/DRS | ||
Inspectors:J. Caruso, Senior Operations | NAME JCaruso/JGC MSykes/MDS BMcDermott/BJM RSummers/RJS WSchmidt/WLS | ||
R. McKinley, Operations Engineer (under-instruction) | DATE 02/05/07 02/05/07 02/07/07 02/06/07 02/06/07 | ||
J. Sullivan, Operations Engineer (under-instruction)Approved by:Marvin D. Sykes, | OFFICE RI/DRS | ||
Division of Reactor Safety | NAME ABlough/ARB | ||
DATE 02/13/07 | |||
significance greater than Green, were identified. | OFFICIAL RECORD COPY | ||
U.S. NUCLEAR REGULATORY COMMISSION | |||
REGION I | |||
Docket No: 50-220, 50-410 | |||
License No: DPR-63, NPF-69 | |||
Report Nos: 05000220/2006011, 05000410/2006011 | |||
Licensee: Nine Mile Point Nuclear Station, LLC (NMPNS) | |||
Facility: Nine Mile Point, Units 1 and 2 | |||
Location: Lake Road | |||
Oswego, NY | |||
Dates: October 16, 2006 - January 9, 2007 | |||
Inspectors: J. Caruso, Senior Operations Engineer | |||
P. Presby, Operations Engineer | |||
R. McKinley, Operations Engineer (under-instruction) | |||
J. Sullivan, Operations Engineer (under-instruction) | |||
Approved by: Marvin D. Sykes, Chief | |||
Operations Branch | |||
Division of Reactor Safety | |||
SUMMARY OF FINDINGS | |||
IR 05000220/2006-011, 05000410/2006-011; 10/16/06 - 1/09/07; Nine Mile Point, Units 1 and | |||
2; Licensed Operator Requalification Program, Inspection Procedure Attachment 71111.11. | |||
This inspection was conducted by two NRC region-based inspectors and two inspectors under | |||
instruction. Three Green findings and one Apparent Violation (AV) with potential safety | |||
significance greater than Green, were identified. The significance of most findings is indicated | |||
by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, | by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, | ||
Significance Determination Process (SDP). Findings for which the SDP does not apply may | |||
be Green or be assigned a severity level after NRC management review. | be Green or be assigned a severity level after NRC management review. The NRCs program | ||
for overseeing the safe operation of commercial nuclear power reactors is described in | for overseeing the safe operation of commercial nuclear power reactors is described in | ||
NUREG-1649, | NUREG-1649, Reactor Oversight Process, Revision 3, dated July 2000. | ||
*TBD. | A. NRC-Identified and Self-Revealing Findings | ||
2006 annual operating exams at Unit 1. | Cornerstone: Mitigating Systems | ||
collectively had the impact of compromising, albeit unintentionally, the | * TBD. An apparent violation of 10 CFR 55.49, Integrity of Examinations and | ||
examinations; these practices included: | Tests, was identified, concerning an apparent compromise of the 2005 and the | ||
diversity (i.e., The scenarios were substantially the same including: | 2006 annual operating exams at Unit 1. NRC inspectors identified practices that | ||
major transients; Emergency Operating Procedure flow paths; and emergency | collectively had the impact of compromising, albeit unintentionally, the | ||
classifications); 2) an overuse of a single emergency operating procedure | examinations; these practices included: 1) a lack of simulator exam scenario | ||
strategy (i.e., full core Anticipated Transient Without Scram); and 3) a pattern of | diversity (i.e., The scenarios were substantially the same including: critical tasks; | ||
crews validating scenarios substantially similar to their exam scenario sets. | major transients; Emergency Operating Procedure flow paths; and emergency | ||
Constellation had not identified and compensated for the compromise prior to | classifications); 2) an overuse of a single emergency operating procedure | ||
completing the 2005 exam and returning the operators to normal control room | strategy (i.e., full core Anticipated Transient Without Scram); and 3) a pattern of | ||
duties. | crews validating scenarios substantially similar to their exam scenario sets. | ||
took immediate and substantive corrective actions prior to completion of the | Constellation had not identified and compensated for the compromise prior to | ||
annual operating exam cycle. | completing the 2005 exam and returning the operators to normal control room | ||
Significance Determination Process (SDP) this finding was preliminarily | duties. Following NRC identification of the compromise in 2006, Constellation | ||
determined to be of low to moderate safety significance (White). | took immediate and substantive corrective actions prior to completion of the | ||
initiated Condition Report CR-NM-2006-4808, dated October 19, 2006, that | annual operating exam cycle. Based on the Licensed Operator Requalification | ||
documented this issue and later initiated a Category I Root Cause Analysis (CR- | Significance Determination Process (SDP) this finding was preliminarily | ||
NM-2006-4808), | determined to be of low to moderate safety significance (White). The licensee | ||
Integrity cornerstones and affected the combined objective of: limiting the | initiated Condition Report CR-NM-2006-4808, dated October 19, 2006, that | ||
likelihood of; ensuring the availability and reliability of mitigating systems to | documented this issue and later initiated a Category I Root Cause Analysis (CR- | ||
respond to; and providing reasonable assurance that physical barriers protect | NM-2006-4808), Annual Licensed Operator Requalification Exam Compromise. | ||
the public from radio-nuclide releases caused by, initiating events.The finding has a cross-cutting aspect in the area of problem identification | This finding was more than minor because it was associated with the Human | ||
Enclosure | Performance attribute of the Initiating Events, Mitigation Systems, and Barrier | ||
appropriately objective, and self-critical such that either Unit 1 2005 exam | Integrity cornerstones and affected the combined objective of: limiting the | ||
compromise issues were avoided altogether or identified and corrected prior to | likelihood of; ensuring the availability and reliability of mitigating systems to | ||
the end of the 2005 annual operating exam cycle. | respond to; and providing reasonable assurance that physical barriers protect | ||
requalification examinations at Unit 2. | the public from radio-nuclide releases caused by, initiating events. | ||
collectively had the impact of compromising, albeit unintentionally; the | The finding has a cross-cutting aspect in the area of problem identification and | ||
examinations, these practices included: | resolution because Constellation did not effectively collect, evaluate, and | ||
diversity (i.e., The scenarios were substantially the same including: | ii Enclosure | ||
major transients; Emergency Operating Procedure flow paths; and emergency | |||
classifications); 2) an overuse of a single emergency operating procedure | communicate applicable external operating experience to affected internal | ||
strategy (i.e., full core Anticipated Transient Without Scram); and 3) a pattern of | stakeholders nor did they conduct self-assessments that were comprehensive, | ||
crews validating scenarios substantially similar to their exam scenario sets. | appropriately objective, and self-critical such that either Unit 1 2005 exam | ||
licensee initiated CR-NM-2006-4808 that documented this concern and later | compromise issues were avoided altogether or identified and corrected prior to | ||
initiated a Category I Root Cause Analysis.This finding was more than minor because it was associated with the | the end of the 2005 annual operating exam cycle. (Section 1R11.1) | ||
Integrity cornerstones and affected the combined objective of: limiting the | * Green. A Green NRC-identified non-cited violation (NCV) of 10CFR55.49 was | ||
likelihood of; ensuring the availability and reliability of mitigating systems to | identified, concerning an apparent compromise of the 2006 annual operating | ||
respond to; and providing reasonable assurance that physical barriers protect | requalification examinations at Unit 2. NRC inspectors identified practices that | ||
the public from radio nuclide releases caused by, initiating events. | collectively had the impact of compromising, albeit unintentionally; the | ||
was assessed as having very low safety significance because immediate and | examinations, these practices included: 1) a lack of simulator exam scenario | ||
substantive corrective actions were taken by Constellation prior to the end of the | diversity (i.e., The scenarios were substantially the same including: critical tasks; | ||
current exam cycle. | major transients; Emergency Operating Procedure flow paths; and emergency | ||
communicate applicable external operating experience to affected internal | classifications); 2) an overuse of a single emergency operating procedure | ||
stakeholders nor did they conduct self-assessments that were comprehensive, | strategy (i.e., full core Anticipated Transient Without Scram); and 3) a pattern of | ||
appropriately objective, and self-critical such that the 2006 Unit 2 exam | crews validating scenarios substantially similar to their exam scenario sets. The | ||
compromise issues were either avoided altogether or at least identified and | licensee initiated CR-NM-2006-4808 that documented this concern and later | ||
corrected by Constellation prior to the start of this inspection. | initiated a Category I Root Cause Analysis. | ||
facility-administered requalification examinations. | This finding was more than minor because it was associated with the Human | ||
two failed to pass their simulator examinations when the newly developed more | Performance attribute of the Initiating Events, Mitigation Systems, and Barrier | ||
comprehensive exams were re-administered in response to the above noted | Integrity cornerstones and affected the combined objective of: limiting the | ||
preliminary White finding. | likelihood of; ensuring the availability and reliability of mitigating systems to | ||
Condition Report | respond to; and providing reasonable assurance that physical barriers protect | ||
Category I Root Cause Analysis. This finding was more than minor because it was associated with the | the public from radio nuclide releases caused by, initiating events. The finding | ||
Integrity cornerstones and affected the combined objective of: limiting the | was assessed as having very low safety significance because immediate and | ||
Enclosure | substantive corrective actions were taken by Constellation prior to the end of the | ||
the public from radio nuclide releases caused by, initiating events. | current exam cycle. | ||
was assessed as having very low safety significance because: 1) the failures | The finding has a cross-cutting aspect in the area of problem identification and | ||
occurred during annual testing of the operators on the simulator; 2) there were | resolution because Constellation did not effectively collect, evaluate, and | ||
no actual consequences to the failures; 3) the crews were removed from watch | communicate applicable external operating experience to affected internal | ||
standing duties, retrained and re-evaluated before they were authorized to return | stakeholders nor did they conduct self-assessments that were comprehensive, | ||
to control room watches; and, 4) because the crew failure rate for the 2005 Unit | appropriately objective, and self-critical such that the 2006 Unit 2 exam | ||
1 Annual Operating Exams was less than 20%. | compromise issues were either avoided altogether or at least identified and | ||
facility-administered requalification examinations. | corrected by Constellation prior to the start of this inspection. (Section 1R11.2) | ||
two failed to pass their simulator examinations when the newly developed more | * Green. A finding of very low safety significance was identified at Unit 1. The | ||
comprehensive exams were re-administered in response to the above noted | finding was associated with crew performance on the simulator during the 2006 | ||
preliminary White finding. | facility-administered requalification examinations. Of the six crews evaluated, | ||
Condition Report | two failed to pass their simulator examinations when the newly developed more | ||
Category I Root Cause Analysis. | comprehensive exams were re-administered in response to the above noted | ||
Integrity cornerstones and affected the combined objective of: limiting the | preliminary White finding. The failures are documented in licensee-initiated | ||
likelihood of; ensuring the availability and reliability of mitigating systems to | Condition Report CR 2006-5797, which resulted in Constellation conducting a | ||
respond to; and providing reasonable assurance that physical barriers protect | Category I Root Cause Analysis. | ||
the public from radio nuclide releases caused by, initiating events. | This finding was more than minor because it was associated with the Human | ||
was assessed as having very low safety significance because: 1) the failures | Performance attribute of the Initiating Events, Mitigation Systems, and Barrier | ||
occurred during annual testing of the operators on the simulator; 2) there were | Integrity cornerstones and affected the combined objective of: limiting the | ||
no actual consequences to the failures; 3) the crews were removed from watch | iii Enclosure | ||
standing duties, retrained and re-evaluated before they were authorized to return | |||
to control room watches; and, 4) because the crew failure rate for the 2005 Unit | likelihood of; ensuring the availability and reliability of mitigating systems to | ||
2 Annual Operating Exams was less than 20%. | respond to; and providing reasonable assurance that physical barriers protect | ||
None. | the public from radio nuclide releases caused by, initiating events. The finding | ||
was assessed as having very low safety significance because: 1) the failures | |||
Attachment 71111.11, | occurred during annual testing of the operators on the simulator; 2) there were | ||
Chapter 0609, Appendix I, | no actual consequences to the failures; 3) the crews were removed from watch | ||
Determination Process (SDP), | standing duties, retrained and re-evaluated before they were authorized to return | ||
dynamic simulator scenarios, three simulator Job Performance Measures (JPMs) and | to control room watches; and, 4) because the crew failure rate for the 2005 Unit | ||
two in plant JPMs for one operations crew. | 1 Annual Operating Exams was less than 20%. (Section 1R11.3) | ||
inspection issues identified, the licensee invalidated all of the dynamic simulator exams | * Green. A finding of very low safety significance was identified at Unit 2. The | ||
for 2006 on both units and initiated development of new 2006 exam scenarios (see | finding was associated with crew performance on the simulator during the 2006 | ||
Findings section of this report for further details). | facility-administered requalification examinations. Of the six crews evaluated, | ||
the scope of this inspection was expanded. | two failed to pass their simulator examinations when the newly developed more | ||
December 4 and December 11, 2006, the inspectors observed and assessed | comprehensive exams were re-administered in response to the above noted | ||
preliminary White finding. The failures are documented in licensee-initiated | |||
operating crews and two of the Unit 2 operating crews. | Condition Report CR 2006-5797, which resulted in Constellation conducting a | ||
observed the administration of retake exam scenarios for one Unit 1 and one Unit 2 | Category I Root Cause Analysis. | ||
operating crew following their exam failures and subsequent training remediations. The inspectors reviewed all three Unit 1 exam sets for both the comprehensive | This finding was more than minor because it was associated with the Human | ||
the newly developed simulator exam scenarios for both Unit 1 and 2, and a sample (i.e., | Performance attribute of the Initiating Events, Mitigation Systems, and Barrier | ||
exam weeks 1, 3, 4) of the Unit 1 JPMs administered during this current exam cycle to | Integrity cornerstones and affected the combined objective of: limiting the | ||
ensure the quality of these exams met or exceeded the criteria established in the | likelihood of; ensuring the availability and reliability of mitigating systems to | ||
Examination Standards and 10 CFR 55.59. | respond to; and providing reasonable assurance that physical barriers protect | ||
exam scenarios administered as part of the 2005 annual operating exams were | the public from radio nuclide releases caused by, initiating events. The finding | ||
reviewed and evaluated as part of an exam compromise extent of condition review. | was assessed as having very low safety significance because: 1) the failures | ||
tests, selected transient tests, and selected scenario-based tests), and a review of | occurred during annual testing of the operators on the simulator; 2) there were | ||
Simulator Deficiency Reports to verify compliance with the requirements of 10 CFR | no actual consequences to the failures; 3) the crews were removed from watch | ||
55.46 and guidance contained in ANSI/ANS-3.5-1998. | standing duties, retrained and re-evaluated before they were authorized to return | ||
reviewed associated with NCV 2004005-02 (Failure of NMP Simulator to Demonstrate | to control room watches; and, 4) because the crew failure rate for the 2005 Unit | ||
Expected Plant Response). | 2 Annual Operating Exams was less than 20%. (Section 1R11.4) | ||
document list attached). | B. Licensee-Identified Findings | ||
None. | |||
resident staff. | iv Enclosure | ||
REPORT DETAILS | |||
1. REACTOR SAFETY | |||
1R11 Licensed Operator Requalification Program (71111.11) | |||
a. Inspection Scope | |||
The following inspection activities were performed using NUREG-1021, Rev. 9, | |||
Operator Licensing Examination Standards for Power Reactors, Inspection Procedure | |||
Attachment 71111.11, Licensed Operator Requalification Program, and NRC Manual | |||
Chapter 0609, Appendix I, Operator Requalification Human Performance Significance | |||
Determination Process (SDP), as acceptance criteria. | |||
During the first onsite inspection week of October 16, 2006, inspectors observed | |||
administration of licensed operator requalification exams on Unit 1, including two | |||
dynamic simulator scenarios, three simulator Job Performance Measures (JPMs) and | |||
two in plant JPMs for one operations crew. Following an NRC debrief on the preliminary | |||
inspection issues identified, the licensee invalidated all of the dynamic simulator exams | |||
for 2006 on both units and initiated development of new 2006 exam scenarios (see | |||
Findings section of this report for further details). As a result of these identified issues | |||
the scope of this inspection was expanded. During the weeks of November 20, | |||
December 4 and December 11, 2006, the inspectors observed and assessed | |||
Constellations administration of newly developed exam scenarios to all six of the Unit 1 | |||
operating crews and two of the Unit 2 operating crews. In addition, the inspectors | |||
observed the administration of retake exam scenarios for one Unit 1 and one Unit 2 | |||
operating crew following their exam failures and subsequent training remediations. | |||
The inspectors reviewed all three Unit 1 exam sets for both the comprehensive Reactor | |||
Operator (RO) and Senior Reactor Operator (SRO) biennial written exams, as well as all | |||
the newly developed simulator exam scenarios for both Unit 1 and 2, and a sample (i.e., | |||
exam weeks 1, 3, 4) of the Unit 1 JPMs administered during this current exam cycle to | |||
ensure the quality of these exams met or exceeded the criteria established in the | |||
Examination Standards and 10 CFR 55.59. In addition, both the Unit 1and 2 simulator | |||
exam scenarios administered as part of the 2005 annual operating exams were | |||
reviewed and evaluated as part of an exam compromise extent of condition review. | |||
Simulator performance was evaluated through observation during the conduct of the | |||
examinations, a review of simulator performance tests (e.g., steady state performance | |||
tests, selected transient tests, and selected scenario-based tests), and a review of | |||
Simulator Deficiency Reports to verify compliance with the requirements of 10 CFR | |||
55.46 and guidance contained in ANSI/ANS-3.5-1998. Corrective actions were | |||
reviewed associated with NCV 2004005-02 (Failure of NMP Simulator to Demonstrate | |||
Expected Plant Response). No significant simulator issues were identified (see | |||
document list attached). | |||
Enclosure | |||
2 | |||
The inspectors reviewed documentation of operating history since the last requalification | |||
program inspection. The inspectors also discussed facility operating events with the | |||
resident staff. Documents reviewed included NRC inspection reports, Plant | |||
Performance Insights, licensee event reports (LERs), and licensee condition reports | Performance Insights, licensee event reports (LERs), and licensee condition reports | ||
(CRs) that involved human performance issues for licensed operators to ensure that | (CRs) that involved human performance issues for licensed operators to ensure that | ||
operational events were not indicative of possible training deficiencies.The following record reviews were conducted: remediation plans for seven cyclic | operational events were not indicative of possible training deficiencies. | ||
eight quarters of time on shift records; and, ten operator license reactivations. On January 9, 2007, the inspectors conducted an in-office review of the | The following record reviews were conducted: remediation plans for seven cyclic written | ||
guidance of NRC Manual Chapter 0609, Appendix I, | exam failures and one evaluated Operating Exam segment; seven medical records; | ||
Performance Significance Determination Process (SDP). | eight quarters of time on shift records; and, ten operator license reactivations. | ||
(Failure rate was 33.33%.)*Individual failure rate on the dynamic simulator test was less than or equal | On January 9, 2007, the inspectors conducted an in-office review of the full | ||
(Failure rate was 33.33%.)*Individual failure rate on the dynamic simulator test was less than or equal | requalification exam results to assess whether pass rates were consistent with the | ||
guidance of NRC Manual Chapter 0609, Appendix I, Operator Requalification Human | |||
annual operating exams at Unit 1. | Performance Significance Determination Process (SDP). Results are listed below. | ||
the compromise prior to completing the 2005 exam and returning the operators to | Unit 1 Results: | ||
normal control room duties. | * Crew failure rate on the dynamic simulator was less than 34%. The threshold for | ||
Constellation took immediate and substantive corrective actions prior to completion of | a Green finding is a failure rate between 20% and 33%. | ||
the annual and biennial operating exam cycles. | (Failure rate was 33.33%.) | ||
Requalification Significance Determination Process (SDP) this was preliminarily of low to | * Individual failure rate on the dynamic simulator test was less than or equal to | ||
moderate safety significance (White).Description. | 20%. (Failure rate was 19.0%.) | ||
portion of both the 2005 and 2006 annual operating tests. | * Individual failure rate on the walk-through test (JPMs) was less than or equal to | ||
considered widespread, because all licensed operator requalification crews were | 20%. (Failure rate was 2.4%.) | ||
affected on both the 2005 and 2006 exams. | * Individual failure rate on the comprehensive biennial written exam was less than | ||
Unit 1 simulator exam scenarios is considered more serious than the 2006 exam | or equal to 20%. (Failure rate was 2.4%) | ||
compromises and the basis for the preliminary White finding since the 2005 apparent | * More than 75% of the individuals passed all portions of the exam (78.5% of the | ||
exam compromises were not corrected by the licensee prior to returning licensed | individuals passed all portions of the exam). | ||
operators to normal watch-standing duties. | Unit 2 Results: | ||
compromises were identified by the NRC and brought to the attention of Constellation | * Crew failure rate on the dynamic simulator was less than 34%. The threshold for | ||
remedial actions were taken to retest all of the operators prior to the end of the exam | a Green finding is a failure rate between 20% and 33%. | ||
cycle.The issue was identified while conducting the Unit 1 biennial Licensed | (Failure rate was 33.33%.) | ||
2006. | * Individual failure rate on the dynamic simulator test was less than or equal to | ||
were substantially the same as the simulator exam scenarios that were later | 20%. (Failure rate was 12.5%.) | ||
administered to these crews as part of their annual operating test, thus preconditioning | * Individual failure rate on the walk-through test (JPMs) was less than or equal to | ||
the operators. | 20%. (Failure rate was 0.0%.) | ||
NMP-TR-1.01-20, Attachment 5, Section B.2 states, | Enclosure | ||
materials to be used on their exams, | |||
requalification exams will contain at least 50% new material. | 3 | ||
* Individual failure rate on the comprehensive biennial written exam was less than | |||
were administered to | or equal to 20%. (Not applicable - not administered this year) | ||
* More than 75% of the individuals passed all portions of the exam (87.2% of the | |||
individuals passed all portions of the exam). | |||
b. Findings | |||
1. Failure to Ensure Integrity of Unit 1 Examinations and Tests | |||
Introduction. An apparent violation of 10 CFR 55.49, Integrity of Examinations and | |||
Tests, was identified, concerning an apparent compromise of the 2005 and the 2006 | |||
annual operating exams at Unit 1. Constellation had not identified and compensated for | |||
the compromise prior to completing the 2005 exam and returning the operators to | |||
normal control room duties. Following NRC identification of the compromise in 2006, | |||
Constellation took immediate and substantive corrective actions prior to completion of | |||
the annual and biennial operating exam cycles. Based on the Licensed Operator | |||
Requalification Significance Determination Process (SDP) this was preliminarily of low to | |||
moderate safety significance (White). | |||
Description. The inspectors identified that the exam practices used by Constellation at | |||
Nine Mile Point resulted in an apparent compromise of the simulator exam scenario | |||
portion of both the 2005 and 2006 annual operating tests. The apparent compromise is | |||
considered widespread, because all licensed operator requalification crews were | |||
affected on both the 2005 and 2006 exams. The apparent compromise of the 2005 | |||
Unit 1 simulator exam scenarios is considered more serious than the 2006 exam | |||
compromises and the basis for the preliminary White finding since the 2005 apparent | |||
exam compromises were not corrected by the licensee prior to returning licensed | |||
operators to normal watch-standing duties. In contrast, in 2006 when the exam | |||
compromises were identified by the NRC and brought to the attention of Constellation | |||
remedial actions were taken to retest all of the operators prior to the end of the exam | |||
cycle. | |||
The issue was identified while conducting the Unit 1 biennial Licensed Operator | |||
Requalification Training (LORT) Program inspection during the week of October 16, | |||
2006. Constellation allowed operating crews to validate simulator exam scenarios that | |||
were substantially the same as the simulator exam scenarios that were later | |||
administered to these crews as part of their annual operating test, thus preconditioning | |||
the operators. These practices did not comply with Constellations procedural guidance, | |||
NMP-TR-1.01-20, Attachment 5, Section B.2 states, Personnel shall not validate any | |||
materials to be used on their exams, and Section D stipulates each section of the | |||
requalification exams will contain at least 50% new material. | |||
Enclosure | |||
4 | |||
The inspectors identified that the scenarios validated by Unit 1 A crew (September 12- | |||
16, 2006) were substantially similar in content to the two simulator exam scenarios that | |||
were administered to A crew on October 17, 2006. With the exception of a few | |||
malfunctions, the scenarios were substantially the same, i.e., the same critical tasks, | malfunctions, the scenarios were substantially the same, i.e., the same critical tasks, | ||
major transients, Emergency Operating Procedure (EOP) flow paths, and emergency | major transients, Emergency Operating Procedure (EOP) flow paths, and emergency | ||
classifications. | classifications. In addition, on October 16, 2006, one day before taking their annual | ||
operating test using scenario #4, | operating test using scenario #4, A crew was administered exam scenario #2 for | ||
validation/practice. | validation/practice. The inspectors determined that scenario #2 was substantially the | ||
same as scenario #4. | same as scenario #4. The inspectors determined that the other crews examined during | ||
the first three weeks of the exam cycle had also validated scenarios that were | the first three weeks of the exam cycle had also validated scenarios that were | ||
substantially similar in content to the simulator exam scenarios administered during their | substantially similar in content to the simulator exam scenarios administered during their | ||
exam weeks.The inspection team further noted that twelve of the sixteen new simulator | exam weeks. | ||
The inspection team further noted that twelve of the sixteen new simulator exam | |||
scenarios developed for the Unit 1 2006 annual operating test cycle involved a full core | |||
Anticipated Transient Without Scram (ATWS) theme and varied primarily by changing | Anticipated Transient Without Scram (ATWS) theme and varied primarily by changing | ||
several malfunctions for each scenario. | several malfunctions for each scenario. This lack of exam diversity, an overuse of the | ||
ATWS theme, and a pattern of crews validating scenarios substantially similar to their | ATWS theme, and a pattern of crews validating scenarios substantially similar to their | ||
exam scenario sets collectively had the effect of compromising the exams. | exam scenario sets collectively had the effect of compromising the exams. In addition, | ||
the over-emphasis on examining the ATWS theme resulted in not testing other | the over-emphasis on examining the ATWS theme resulted in not testing other | ||
important EOP mitigation strategies (e.g., secondary containment and radiation release | important EOP mitigation strategies (e.g., secondary containment and radiation release | ||
strategies). | strategies). Furthermore, the inspectors determined that the scenario exam sets | ||
previously administered during weeks 1 and 2 were scheduled to be re-administered | previously administered during weeks 1 and 2 were scheduled to be re-administered | ||
during exam weeks 5 and 6 respectively.The NRC inspection team communicated these issues to Constellation representatives. | during exam weeks 5 and 6 respectively. | ||
NRC inspection | The NRC inspection team communicated these issues to Constellation representatives. | ||
On October 20, 2006, representatives of Constellation management agreed with the | |||
NRC inspection teams assessment of the issues. Constellation determined that the | |||
2006 Unit 1 and 2 annual license simulator exam scenarios administered to date were | 2006 Unit 1 and 2 annual license simulator exam scenarios administered to date were | ||
invalid due to the pervasive nature of the apparent exam compromise. | invalid due to the pervasive nature of the apparent exam compromise. Exam | ||
administration was suspended at both units pending development of new exams. | administration was suspended at both units pending development of new exams. The | ||
licensee initiated Condition Report CR-NM-2006-4808, dated October 19, 2006 that | licensee initiated Condition Report CR-NM-2006-4808, dated October 19, 2006 that | ||
documented this issue and later initiated a Category I Root Cause Analysis (CR-NM- | documented this issue and later initiated a Category I Root Cause Analysis (CR-NM- | ||
2006-4808), | 2006-4808), Annual Licensed Operator Requalification Exam Compromise. Note: A | ||
Category I Root Cause Analysis is conducted by independent parties, involves a | Category I Root Cause Analysis is conducted by independent parties, involves a | ||
thorough investigation of the details that led to the problem, identifies the root as well as | thorough investigation of the details that led to the problem, identifies the root as well as | ||
contributing causes, and assigns corrective actions to prevent re-occurrence of the | contributing causes, and assigns corrective actions to prevent re-occurrence of the | ||
problem. | problem. | ||
operating tests. | Following the onsite visit, the NRC inspection team conducted an in-office extent of | ||
compromised and this problem went undetected and uncorrected by the licensee. | condition review of the Unit 1 2005 simulator exam scenario portion of the annual | ||
operating tests. The team determined that the 2005 simulator exam scenarios were | |||
compromised and this problem went undetected and uncorrected by the licensee. The | |||
problem remained undetected until it was identified by the NRC and brought to the | problem remained undetected until it was identified by the NRC and brought to the | ||
attention of Constellation. | attention of Constellation. The problems with the 2005 simulator exam scenarios were | ||
similar to those identified on the 2006 dynamic exams and included a lack of exam | similar to those identified on the 2006 dynamic exams and included a lack of exam | ||
diversity, an overuse of the ATWS theme (8 of 11 scenarios), and a pattern of crews | diversity, an overuse of the ATWS theme (8 of 11 scenarios), and a pattern of crews | ||
Enclosure | |||
5 | |||
validating scenarios that were substantially similar to their exam scenario sets. In | |||
contrast to the 2006 exam, the compromise to the simulator scenario exam portion of | |||
2005 annual operating test was undetected and uncorrected, led to licensed operators | 2005 annual operating test was undetected and uncorrected, led to licensed operators | ||
returning to normal watch-standing duties without adequate compensatory actions being | returning to normal watch-standing duties without adequate compensatory actions being | ||
taken and therefore, is the basis for the preliminary White finding.Inspectors conducted interviews with the exam development team and | taken and therefore, is the basis for the preliminary White finding. | ||
Inspectors conducted interviews with the exam development team and reviewed | |||
associated development records for the 2005 and 2006 exams. Based on this review, it | |||
appeared that the exam compromise issue resulted from NMP staff inexperience and | appeared that the exam compromise issue resulted from NMP staff inexperience and | ||
lack of management oversight of the exam development process. | lack of management oversight of the exam development process. Constellations | ||
emphasis on maintaining exam security resulted in self-imposed restrictions on | emphasis on maintaining exam security resulted in self-imposed restrictions on | ||
management oversight of the exam development process. | management oversight of the exam development process. In addition, the exam | ||
development team operated under some misconceptions including: | development team operated under some misconceptions including: 1) due to a recent | ||
upgrade to the simulator model, rather than modifying existing exam scenarios, the | upgrade to the simulator model, rather than modifying existing exam scenarios, the | ||
exam team needed to draft all new simulator exam scenarios; | exam team needed to draft all new simulator exam scenarios; 2) all revisions to exam | ||
scenarios had to be validated by an operating crew which, in some cases, resulted in | scenarios had to be validated by an operating crew which, in some cases, resulted in | ||
multiple crew exposures to a single scenario; 3) minor revisions to an exam scenario | multiple crew exposures to a single scenario; 3) minor revisions to an exam scenario | ||
Line 361: | Line 521: | ||
advance; and 5) each exam had to include events which challenged one or more critical | advance; and 5) each exam had to include events which challenged one or more critical | ||
tasks from a small pre-existing list of critical tasks which did not encompass the full | tasks from a small pre-existing list of critical tasks which did not encompass the full | ||
range of major events. | range of major events. These misconceptions resulted in a narrowly focused exam | ||
which over-tested the ATWS theme at the exclusion of other equally important EOP | which over-tested the ATWS theme at the exclusion of other equally important EOP | ||
mitigation strategies. | mitigation strategies. The inspectors did not find any indication that the compromises | ||
were intentional.The | were intentional. | ||
The licensees root cause team later concluded, ...that similarities in the scenarios in | |||
the 2006 Unit 1 exam set caused unintentional preconditioning of the crew by exposing | |||
them to scenarios during validation that were essentially the same as the scenarios | them to scenarios during validation that were essentially the same as the scenarios | ||
used for their exam ... and reviewed the 2005 Unit 1 exam sets and found issues | used for their exam ... and reviewed the 2005 Unit 1 exam sets and found issues similar | ||
to those associated with the 2006 Unit 1 exam. The root cause team identified two | |||
primary causes: 1) policy guidance, management expectations, and job performance | primary causes: 1) policy guidance, management expectations, and job performance | ||
standards were not well-defined or understood, the process provides minimal direction | standards were not well-defined or understood, the process provides minimal direction | ||
and guidance, which the inexperienced team was not able to compensate for through | and guidance, which the inexperienced team was not able to compensate for through | ||
their knowledge; and 2) a rigorous review and analysis of the exam by an experienced | their knowledge; and 2) a rigorous review and analysis of the exam by an experienced | ||
exam author did not occur during the review/challenge process. | exam author did not occur during the review/challenge process. No one outside the | ||
immediate exam development team performed a comprehensive exam set review.New and more comprehensive simulator scenario exams were developed | immediate exam development team performed a comprehensive exam set review. | ||
New and more comprehensive simulator scenario exams were developed and | |||
administered to all licensed operators between November 20 and December 14, 2006. | |||
The inspection team observed the re-testing of all Unit 1 licensed operators and noted | The inspection team observed the re-testing of all Unit 1 licensed operators and noted | ||
the following improvements: | the following improvements: 1) development and administration of new, more | ||
comprehensive simulator exam scenarios; 2) one-on-one operator evaluations; 3) | comprehensive simulator exam scenarios; 2) one-on-one operator evaluations; 3) | ||
rotating watch positions for the SROs as well as the ROs between scenarios; 4) | rotating watch positions for the SROs as well as the ROs between scenarios; 4) | ||
evaluation of Shift Technical Advisor position; and 5) conducting more detailed post | evaluation of Shift Technical Advisor position; and 5) conducting more detailed post | ||
exam critiques. | exam critiques. | ||
Enclosure | |||
6 | |||
Analysis. The unintentional integrity comprise of the simulator exam scenario portion of | |||
the Unit 1 2005 and 2006 annual operating exams was a performance deficiency, in that | |||
Constellation failed to follow their established requalification procedures and resulted in | Constellation failed to follow their established requalification procedures and resulted in | ||
an apparent violation of 10 CFR 55.49. | an apparent violation of 10 CFR 55.49. Integrity of Exams and Tests. Specifically, in | ||
2005 and initially in 2006 the operators were tested using requalification simulator exam | 2005 and initially in 2006 the operators were tested using requalification simulator exam | ||
scenarios substantially similar to simulator exam scenarios that they had previously | scenarios substantially similar to simulator exam scenarios that they had previously | ||
validated. | validated. Therefore, the validation process, in combination with a lack of exam | ||
diversity, caused exam integrity to be compromised. | diversity, caused exam integrity to be compromised. Traditional enforcement does not | ||
apply because the issue did not have any actual safety consequences, potential for | apply because the issue did not have any actual safety consequences, potential for | ||
impacting the | impacting the NRCs regulatory function, and was not the result of any willful violation of | ||
NRC requirements or | NRC requirements or Constellations procedures. This finding was more than minor | ||
because it was associated with the Human Performance attribute of the Initiating | because it was associated with the Human Performance attribute of the Initiating | ||
Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the | Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the | ||
combined objective of: limiting the likelihood of; ensuring the availability and reliability of | combined objective of: limiting the likelihood of; ensuring the availability and reliability of | ||
mitigating systems to respond to; and providing reasonable assurance that physical | mitigating systems to respond to; and providing reasonable assurance that physical | ||
barriers protect the public from radio nuclide releases caused by, initiating events.This finding was determined preliminarily to have low to moderate safety significance(White) using the Licensed Operator Requalification Human Performance Significance | barriers protect the public from radio nuclide releases caused by, initiating events. | ||
Determination Process (SDP) Inspection Manual Chapter 0609, Appendix I. | This finding was determined preliminarily to have low to moderate safety significance | ||
applies, | (White) using the Licensed Operator Requalification Human Performance Significance | ||
control the scenario identity or material including the | Determination Process (SDP) Inspection Manual Chapter 0609, Appendix I. Block 21 | ||
operating test integrity is affected | applies, Has the integrity of the scenario been compromised? This is a failure to | ||
control the scenario identity or material including the validation process such that the | |||
operating test integrity is affected. The answer to the Block 21 question is yes, the | |||
operators were tested using requalification exam scenarios substantially similar to exam | operators were tested using requalification exam scenarios substantially similar to exam | ||
scenarios that they had previously validated. | scenarios that they had previously validated. Therefore, the validation process, in | ||
combination with a lack of scenario diversity, led to an unintentional exam compromise.Block 26 also applies, | combination with a lack of scenario diversity, led to an unintentional exam compromise. | ||
discovered, did the licensee take immediate compensatory measures | Block 26 also applies, When the compromise was discovered, or should have been | ||
discovered, did the licensee take immediate compensatory measures. The answer to | |||
the Block 26 question is no, as Constellation did not identify and take immediate | |||
corrective actions for the 2005 Unit 1 exam compromises (Block 21 - Yes and Block 26 - | corrective actions for the 2005 Unit 1 exam compromises (Block 21 - Yes and Block 26 - | ||
No). | No). This simulator exam scenario integrity compromise finding should have been | ||
discovered and corrected by Constellation, prior to NRC identification. | discovered and corrected by Constellation, prior to NRC identification. Constellation | ||
should have discovered the problem in 2005 or at least prior to the | should have discovered the problem in 2005 or at least prior to the NRCs identification | ||
because: 1) a similar issue was described in 2002 Industry Operating Experience | because: 1) a similar issue was described in 2002 Industry Operating Experience | ||
involving exam compromise; | involving exam compromise; 2) Constellation completed a self audit in August 2006 that | ||
failed to identify this issue; and 3) the practices clearly violated NRC guidance and | failed to identify this issue; and 3) the practices clearly violated NRC guidance and | ||
requirements, as well as | requirements, as well as Constellations procedural guidance aimed at preventing exam | ||
compromise. | compromise. More importantly, however, in 2005, because the issue was not identified | ||
at the time, Constellation had not taken compensatory actions prior to returning the | at the time, Constellation had not taken compensatory actions prior to returning the | ||
operators to normal control room duties. | operators to normal control room duties. Following identification of this issue by the | ||
NRC, the licensee took immediate and substantive corrective actions to remedy the | NRC, the licensee took immediate and substantive corrective actions to remedy the | ||
2006 annual operating exam compromise, by developing new exams and re-testing all | 2006 annual operating exam compromise, by developing new exams and re-testing all | ||
the Unit 1 licensed operators within the required annual and biennial exam cycles. The cause of the finding has a cross-cutting aspect in the area of problem | the Unit 1 licensed operators within the required annual and biennial exam cycles. | ||
The cause of the finding has a cross-cutting aspect in the area of problem identification | |||
appropriately objective and self-critical such that the Unit 1 2005 exam compromise | and resolution in that Constellation did not effectively collect, evaluate, and | ||
issues were avoided altogether or at least identified and corrected prior to the end of the | Enclosure | ||
2005 annual operating exam cycle. Enforcement. 10 CFR 55.49, requires, in part, that, | |||
by this part. The integrity of a test or examination is considered compromised if any | 7 | ||
activity, regardless of intent, affected, or, but for detection, would have affected the | communicate applicable external operating experience to affected internal stakeholders | ||
equitable and consistent administration of the test or exam. | nor did they conduct self-assessments of sufficient depth that were comprehensive, | ||
requirement, the Unit 1 2005 and 2006 annual operating tests were compromised since | appropriately objective and self-critical such that the Unit 1 2005 exam compromise | ||
the process used to validate the simulator exam scenarios resulted in licensed operators | issues were avoided altogether or at least identified and corrected prior to the end of the | ||
being knowledgeable of a significant portion of the test prior to its administration.This finding was not an immediate safety concern for the following reasons: 1) | 2005 annual operating exam cycle. | ||
abilities; 2) all licensed operators had participated in a continuous requalification training | Enforcement. 10 CFR 55.49, requires, in part, that, ...licensees shall not engage in any | ||
program; 3) this issue, while pervasive, was limited to the 2005 and 2006 exams and did | activity that compromises the integrity of any application, test, or examination required | ||
not extend to the 2004 exams; 4) Constellation took immediate remedial actions by | by this part. The integrity of a test or examination is considered compromised if any | ||
administering new and more comprehensive simulator exam scenarios to all Unit 1 | activity, regardless of intent, affected, or, but for detection, would have affected the | ||
licensed operators upon discovery of this concern by the NRC. | equitable and consistent administration of the test or exam. Contrary to this | ||
crew weaknesses were identified, as evidenced by the individual and crew failure rates,however the performance on these new exams was overall satisfactory. | requirement, the Unit 1 2005 and 2006 annual operating tests were compromised since | ||
operating exams at Unit 2. | the process used to validate the simulator exam scenarios resulted in licensed operators | ||
Constellation took adequate compensatory measures, prior to completion of the annual | being knowledgeable of a significant portion of the test prior to its administration. | ||
and biennial exam cycles.Description. | This finding was not an immediate safety concern for the following reasons: 1) there | ||
the 2006 annual operating tests.The | were no significant plant performance issues related to operator knowledge and | ||
simulator exam scenarios that were substantially the same as the simulator exam | abilities; 2) all licensed operators had participated in a continuous requalification training | ||
scenarios that were later administered to these crews as part of their annual operating | program; 3) this issue, while pervasive, was limited to the 2005 and 2006 exams and did | ||
test, thus preconditioning the operators (see preliminary white finding discussed in item | not extend to the 2004 exams; 4) Constellation took immediate remedial actions by | ||
b.1 above for details). | administering new and more comprehensive simulator exam scenarios to all Unit 1 | ||
guidance, in NMP-TR-1.01-20, Attachment 5, Section B.2 which states, | licensed operators upon discovery of this concern by the NRC. Some individual and | ||
not validate any materials to be used on their exams, | crew weaknesses were identified, as evidenced by the individual and crew failure rates, | ||
however the performance on these new exams was overall satisfactory. (AV 50- | |||
NRC inspection | 220/2006011-01, Failure to Ensure Integrity of Unit 1 Examinations and Tests) | ||
2. Failure to Ensure Integrity of Unit 2 Examinations and Tests | |||
Introduction. A non-cited violation of 10 CFR 55.49, Integrity of Examinations and | |||
Tests, was identified, concerning an apparent compromise of the 2006 annual | |||
operating exams at Unit 2. Following NRC identification of the compromise, | |||
Constellation took adequate compensatory measures, prior to completion of the annual | |||
and biennial exam cycles. | |||
Description. The inspectors identified that the exam practices used by Constellation at | |||
Nine Mile Point resulted in an apparent compromise of the dynamic scenario portion | |||
the 2006 annual operating tests. | |||
The issue was identified while conducting the Unit 1 biennial LORT Program inspection | |||
during the week of October 16, 2006. Constellation allowed operating crews to validate | |||
simulator exam scenarios that were substantially the same as the simulator exam | |||
scenarios that were later administered to these crews as part of their annual operating | |||
test, thus preconditioning the operators (see preliminary white finding discussed in item | |||
b.1 above for details). These practices did not comply with Constellations procedural | |||
guidance, in NMP-TR-1.01-20, Attachment 5, Section B.2 which states, Personnel shall | |||
not validate any materials to be used on their exams, and Section D which stipulates | |||
Enclosure | |||
8 | |||
each section of the requalification exams will contain at least 50% new material. | |||
The NRC inspection team communicated these issues to Constellation representatives. | |||
On October 20, 2006, representatives of Constellation management agreed with the | |||
NRC inspection teams assessment of the issues. The licensee then conducted an | |||
extent of condition review for Unit 2 annual license operating tests administered to date | extent of condition review for Unit 2 annual license operating tests administered to date | ||
and determined the exams administered to date were invalid due to the pervasive nature | and determined the exams administered to date were invalid due to the pervasive nature | ||
of the apparent exam compromise. | of the apparent exam compromise. Exam administration was suspended at both units | ||
pending development of new exams. | pending development of new exams. The licensee initiated Condition Report CR-NM- | ||
2006-4808, dated October 19, 2006 that documented this issue and later initiated a | 2006-4808, dated October 19, 2006 that documented this issue and later initiated a | ||
Category I Root Cause Analysis (CR-NM-2006-4808), | Category I Root Cause Analysis (CR-NM-2006-4808), Annual Licensed Operator | ||
Requalification Exam Compromise. | Requalification Exam Compromise. | ||
the 2005 Unit 2 dynamic exams were not affected.The | Following the onsite visit, the NRC inspection team conducted an in-office extent of | ||
condition review of the Unit 2 2005 dynamic operating tests. The team determined that | |||
the 2005 Unit 2 dynamic exams were not affected. | |||
The licensees root cause team later concluded, ...that similarities in the scenarios in | |||
the 2006 Unit 1 exam set caused unintentional preconditioning of the crew by exposing | |||
them to scenarios during validation that were essentially the same as the scenarios | them to scenarios during validation that were essentially the same as the scenarios | ||
used for their exam ... and reviewed the 2006 Unit 2 and 2005 Unit 1 exam sets and | used for their exam ... and reviewed the 2006 Unit 2 and 2005 Unit 1 exam sets and | ||
found issues similar to those associated with the 2006 Unit 1 exam. | found issues similar to those associated with the 2006 Unit 1 exam. | ||
New and more comprehensive scenario exam scenarios were developed and | |||
administered to all licensed operators between November 20 and December 14, 2006. | |||
The inspection team observed the re-testing of all Unit 1 and some of the Unit 2 licensed | The inspection team observed the re-testing of all Unit 1 and some of the Unit 2 licensed | ||
operators.Analysis. | operators. | ||
Analysis. The unintentional integrity compromise of the simulator exam scenario portion | |||
of the 2006 Unit 2 annual operator exams was a performance deficiency, in that | |||
Constellation failed to follow their established requalification procedures and violated | Constellation failed to follow their established requalification procedures and violated | ||
10 CFR 55.49. | 10 CFR 55.49. Integrity of Exams and Tests. Specifically, initially in 2006 the | ||
operators were tested using simulator exam scenarios substantially similar to simulator | operators were tested using simulator exam scenarios substantially similar to simulator | ||
exam scenarios that they had previously validated. | exam scenarios that they had previously validated. Therefore, the validation process, in | ||
combination with a lack of exam diversity, caused exam integrity to be compromised. | combination with a lack of exam diversity, caused exam integrity to be compromised. | ||
Traditional enforcement does not apply because the issue did not have any actual safety | Traditional enforcement does not apply because the issue did not have any actual safety | ||
consequences or potential for impacting the | consequences or potential for impacting the NRCs regulatory function and was not the | ||
result of any willful violation of NRC requirements or | result of any willful violation of NRC requirements or Constellations procedures. This | ||
finding was more than minor because it was associated with the Human Performance | finding was more than minor because it was associated with the Human Performance | ||
attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones | attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones | ||
Line 470: | Line 675: | ||
and reliability of mitigating systems to respond to; and providing reasonable assurance | and reliability of mitigating systems to respond to; and providing reasonable assurance | ||
that physical barriers protect the public from radio nuclide releases caused by, initiating | that physical barriers protect the public from radio nuclide releases caused by, initiating | ||
events.This finding was determined to have very low safety significance (Green) | events. | ||
This finding was determined to have very low safety significance (Green) using | |||
to the Block 21 question is | Appendix I of the SDP. Block 21 applies, Has the integrity of the scenario been | ||
scenarios substantially similar to exam scenarios that they had previously validated. | Enclosure | ||
Therefore, the validation process in combination with a lack of scenario diversity, led to | |||
an exam compromise. | 9 | ||
or should have been discovered, did the licensee take immediate compensatory | compromised? This is a failure to control the scenario identity or material including | ||
measures | the validation process such that the operating test integrity is affected. The answer | ||
green finding (Block 21 - Yes and Block 26 - Yes), | to the Block 21 question is yes, the operators were tested using requalification exam | ||
integrity compromise finding should have been discovered and corrected prior to NRC | scenarios substantially similar to exam scenarios that they had previously validated. | ||
identification. | Therefore, the validation process in combination with a lack of scenario diversity, led to | ||
substantive compensatory actions to remedy the 2006 annual operating exam | an exam compromise. Block 26 also applies, When the compromise was discovered, | ||
compromise, by developing new exams and re-testing all the Unit 2 licensed operators | or should have been discovered, did the licensee take immediate compensatory | ||
within the required annual and biennial exam cycles. | measures also applies. The answer to the Block 26 question is yes resulting in a | ||
that the Unit 2 2005 simulator exam scenario portion of the annual operating exam had | green finding (Block 21 - Yes and Block 26 - Yes), This simulator exam scenario | ||
not been compromised in a similar fashion. The cause of the finding has a cross-cutting aspect in the area of problem | integrity compromise finding should have been discovered and corrected prior to NRC | ||
communicate applicable external operating experience to affected internal stakeholders | identification. However, following identification Constellation took immediate and | ||
nor did they conduct self-assessments of sufficient depth that were comprehensive, | substantive compensatory actions to remedy the 2006 annual operating exam | ||
appropriately objective and self-critical such that the 2006 Unit 2 exam compromise | compromise, by developing new exams and re-testing all the Unit 2 licensed operators | ||
issues were either avoided altogether or at least identified and corrected by | within the required annual and biennial exam cycles. Further, the inspectors verified | ||
Constellation prior to the start of this inspection.Enforcement. | that the Unit 2 2005 simulator exam scenario portion of the annual operating exam had | ||
by this part. | not been compromised in a similar fashion. | ||
activity, regardless of intent, affected, or, but for detection, would have affected the | The cause of the finding has a cross-cutting aspect in the area of problem identification | ||
equitable and consistent administration of the test or exam. | and resolution in that Constellation did not effectively collect, evaluate, and | ||
requirement, the 2006 Unit 2 annual operating tests were compromised since the | communicate applicable external operating experience to affected internal stakeholders | ||
process used to validate the simulator exam scenarios resulted in licensed operators | nor did they conduct self-assessments of sufficient depth that were comprehensive, | ||
being knowledgeable of a significant portion of the test prior to its administration.(NCV 05000410/2006011-02, Failure to Ensure Integrity of Unit 2 Examinations | appropriately objective and self-critical such that the 2006 Unit 2 exam compromise | ||
examinations.Description. | issues were either avoided altogether or at least identified and corrected by | ||
scenarios using performance standards derived from NUREG-1021, | Constellation prior to the start of this inspection. | ||
Enforcement. 10 CFR 55.49, requires, in part, that, ...licensees shall not engage in any | |||
simulator exams. | activity that compromises the integrity of any application, test, or examination required | ||
by this part. The integrity of a test or examination is considered compromised if any | |||
activity, regardless of intent, affected, or, but for detection, would have affected the | |||
equitable and consistent administration of the test or exam. Contrary to this | |||
requirement, the 2006 Unit 2 annual operating tests were compromised since the | |||
process used to validate the simulator exam scenarios resulted in licensed operators | |||
being knowledgeable of a significant portion of the test prior to its administration. | |||
(NCV 05000410/2006011-02, Failure to Ensure Integrity of Unit 2 Examinations and | |||
Tests) | |||
3. Unit 1 Crew Failure Rate on the Dynamic Simulator Portion of the Annual Operating | |||
Examinations | |||
Introduction. A finding of very low safety significance (Green) was identified at Unit 1, | |||
based on two of six crews failing their facility-administered annual simulator | |||
examinations. | |||
Description. During facility-administered annual operating testing of the licensed | |||
operators, licensee training staff evaluated crew performance on simulator exam | |||
scenarios using performance standards derived from NUREG-1021, Operator | |||
Enclosure | |||
10 | |||
Licensing Examination Standards for Power Reactors. Facility results of crew | |||
performance showed that two of the six crews evaluated (33%) did not pass their | |||
simulator exams. The failures are documented in licensee-initiated Condition Report | |||
CR 2006-5797, which resulted in Constellation conducting a Category I Root Cause | CR 2006-5797, which resulted in Constellation conducting a Category I Root Cause | ||
Analysis. | Analysis. Constellations root cause analysis report stated, The number of individual | ||
and crew failures could be indicative of programmatic weaknesses that if unresolved, | and crew failures could be indicative of programmatic weaknesses that if unresolved, | ||
could affect operator performance on shift, ... 9 of 14 individuals failing the | could affect operator performance on shift, ... 9 of 14 individuals failing the annual | ||
annual exam (within the last 2 years). | operating exam had been noted as needing improvement in the same areas as on the | ||
annual exam (within the last 2 years). 3 of 4 crews failing the annual exam failed a | |||
recent evaluated scenario (in 2006) and all 4 crews had failed a scenario in the last 2 | recent evaluated scenario (in 2006) and all 4 crews had failed a scenario in the last 2 | ||
years. | years. Ops Management was not fully aware of these performance weaknesses. Other | ||
than documentation of remediation for failures, no other documentation was found as | than documentation of remediation for failures, no other documentation was found as | ||
described performance improvement plans for individuals noted as needing | described performance improvement plans for individuals noted as needing | ||
improvement as required by GAI-OPS-13. | improvement as required by GAI-OPS-13. GAI-OPS-13, Attachment 1.2, states that, | ||
...a score of one or two in any competency area or on any event or evolution requires | |||
development of a plan for improving performance. NRC inspectors observed the | |||
administration of the simulator exam scenario evaluations for all six crews and also | administration of the simulator exam scenario evaluations for all six crews and also | ||
observed the retest of one of the remediated crews that failed their exam during a | observed the retest of one of the remediated crews that failed their exam during a | ||
previous week.Analysis. | previous week. | ||
LORT program were not utilized. | Analysis. A performance deficiency (PD) was identified in that the Systems Approach to | ||
appropriately identified, evaluated and corrective actions taken. | Training (SAT) feedback mechanism standards associated with the Nine Mile Point | ||
LORT program were not utilized. Specifically, individual and crew weaknesses were not | |||
appropriately identified, evaluated and corrective actions taken. In addition, corrective | |||
actions taken for previously identified individual and crew weaknesses were not fully | actions taken for previously identified individual and crew weaknesses were not fully | ||
effective (i.e., a Category 1 CR written in 2004 to document a green finding from crew | effective (i.e., a Category 1 CR written in 2004 to document a green finding from crew | ||
failures on an annual exam). | failures on an annual exam). As a result, two of six licensed operator crews | ||
demonstrated knowledge and ability weaknesses resulting in less than adequate | demonstrated knowledge and ability weaknesses resulting in less than adequate | ||
performance on an NRC required requalification test administered by the licensee. | performance on an NRC required requalification test administered by the licensee. | ||
Traditional enforcement does not apply because the issue did not have any actual safety | Traditional enforcement does not apply because the issue did not have any actual safety | ||
consequence or potential for affecting the | consequence or potential for affecting the NRCs regulatory function and was not the | ||
result of any willful violation of NRC requirements or licensee procedures. | result of any willful violation of NRC requirements or licensee procedures. This finding | ||
was more than minor because it was associated with the Human Performance attribute | was more than minor because it was associated with the Human Performance attribute | ||
of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and | of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and | ||
Line 530: | Line 761: | ||
reliability of mitigating systems to respond to; and providing reasonable assurance that | reliability of mitigating systems to respond to; and providing reasonable assurance that | ||
physical barriers protect the public from radio nuclide releases caused by, initiating | physical barriers protect the public from radio nuclide releases caused by, initiating | ||
events. | events. Specifically, the finding reflected the potential inability of the crews to take | ||
appropriate safety-related actions in response to actual abnormal or emergency | appropriate safety-related actions in response to actual abnormal or emergency | ||
conditions while they were on-shift prior to the requalification testing.Since this is a more than minor requalification training issue, the risk | conditions while they were on-shift prior to the requalification testing. | ||
Appendix I of the SDP. | Since this is a more than minor requalification training issue, the risk importance | ||
associated with the number of crews failing the annual operating tests is provided in | |||
Appendix I of the SDP. The Simulator Operational Evaluation Matrix was entered using | |||
the number of crews that took the simulator test, six, and the number of crews with less | the number of crews that took the simulator test, six, and the number of crews with less | ||
than adequate performance, two. | than adequate performance, two. Based on these numbers, the finding was | ||
characterized by the SDP as having very low safety significance (20 - 34% failure rate), | characterized by the SDP as having very low safety significance (20 - 34% failure rate), | ||
or Green. The finding is of very low safety significance because the failures occurred | Enclosure | ||
during annual testing of the operators on the simulator, because there were no actual | |||
consequences to the failures, because the crews were removed from watch standing | 11 | ||
duties, retrained, and re-evaluated before they were authorized to return to control room | or Green. The finding is of very low safety significance because the failures occurred | ||
watches, and because the crew failure rate for the 2005 Unit 2 Annual Operating Exams | during annual testing of the operators on the simulator, because there were no actual | ||
was less than 20%. | consequences to the failures, because the crews were removed from watch standing | ||
requirements are met by restricting the operator from licensed duties until the operator | duties, retrained, and re-evaluated before they were authorized to return to control room | ||
has been retrained and successfully retested, steps which licensee staff completed. | watches, and because the crew failure rate for the 2005 Unit 1 Annual Operating Exams | ||
Therefore, no violation of regulatory requirements occurred. | was less than 20%. | ||
2006 annual operating exams has been entered into the corrective action program | Enforcement. NRC regulations require that licensed operators pass an annual | ||
(CAP) as CR 2006-5797, and Constellation performed a level 1 root cause analysis | operating test; the regulations do not specify pass/fail rates. When a failure occurs, | ||
requirements are met by restricting the operator from licensed duties until the operator | |||
has been retrained and successfully retested, steps which licensee staff completed. | |||
that this item will remain open pending further NRC review (i.e., the NRC has not | Therefore, no violation of regulatory requirements occurred. Crew performance on the | ||
reached final resolution with the industry regarding an acceptable level of | 2006 annual operating exams has been entered into the corrective action program | ||
conclusion of the inspection on January 18, 2007. | (CAP) as CR 2006-5797, and Constellation performed a level 1 root cause analysis of | ||
identified by the licensee as proprietary. | these crew failures. (FIN 05000220/2006011-03, Unit 1 Crew Failure Rate on the | ||
A- | Dynamic Simulator Portion of the Annual Operating Examinations) | ||
4. Unit 2 Crew Failure Rate on the Dynamic Simulator Portion of the Annual Operating | |||
Examinations | |||
Introduction. A finding of very low safety significance (Green) was identified at Unit 2, | |||
based on two of six crews failing their facility-administered annual simulator | |||
examinations. | |||
Description. During facility-administered annual operating testing of the licensed | |||
operators, licensee training staff evaluated crew performance on simulator exam | |||
scenarios using performance standards derived from NUREG-1021, Operator | |||
Licensing Examination Standards for Power Reactors. Facility results of crew | |||
performance showed that two of the six crews evaluated (33%) did not pass their | |||
simulator exams. The failures are documented in licensee-initiated Condition Report | |||
CR 2006-5797, which resulted in Constellation conducting a Category I Root Cause | |||
Analysis. Constellations root cause analysis report stated, The number of individual | |||
and crew failures could be indicative of a programmatic weaknesses that if unresolved, | |||
could affect operator performance on shift, ... 9 of 14 individuals failing the annual | |||
operating exam had been noted as needing improvement in the same areas as on the | |||
annual exam (within the last 2 years). 3 of 4 crews failing the annual exam failed a | |||
recent evaluated scenario (in 2006) and all 4 crews had failed a scenario in the last 2 | |||
years. Ops Management was not fully aware of these performance weaknesses. Other | |||
than documentation of remediation for failures, no other documentation was found as | |||
described performance improvement plans for individuals noted as needing | |||
improvement as required by GAI-OPS-13. GAI-OPS-13, Attachment 1.2, states that, | |||
...a score of one or two in any competency area or on any event or evolution requires | |||
development of a plan for improving performance. NRC inspectors observed the | |||
administration of the simulator exam scenario evaluations for two of six crews and also | |||
observed the retest of one of the remediated crews that failed their exam during a | |||
previous week. | |||
Enclosure | |||
12 | |||
Analysis. A performance deficiency (PD) was identified in that the Systems Approach to | |||
Training (SAT) feedback mechanism standards associated with the Nine Mile Point | |||
LORT program were not utilized. Specifically, individual and crew weaknesses were not | |||
appropriately identified, evaluated and corrective actions taken. In addition, corrective | |||
actions taken for previously identified individual and crew weaknesses were not fully | |||
effective (i.e., a Category 1 CR written in 2004 to document a green finding from crew | |||
failures on an annual exam). As a result, two of six licensed operator crews | |||
demonstrated knowledge and ability weaknesses resulting in less than adequate | |||
performance on an NRC required requalification test administered by the licensee. | |||
Traditional enforcement does not apply because the issue did not have any actual safety | |||
consequence or potential for affecting the NRCs regulatory function and was not the | |||
result of any willful violation of NRC requirements or licensee procedures. This finding | |||
was more than minor because it was associated with the Human Performance attribute | |||
of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and | |||
affected the combined objective of: limiting the likelihood of; ensuring the availability and | |||
reliability of mitigating systems to respond to; and providing reasonable assurance that | |||
physical barriers protect the public from radio nuclide releases caused by, initiating | |||
events. Specifically, the finding reflected the potential inability of the crews to take | |||
appropriate safety-related actions in response to actual abnormal or emergency | |||
conditions while they were on-shift prior to the requalification testing. | |||
Since this is a more than minor requalification training issue, the risk importance | |||
associated with the number of crews failing the annual operating tests is provided in | |||
Appendix I of the SDP. The Simulator Operational Evaluation Matrix was entered using | |||
the number of crews that took the simulator test, six, and the number of crews with less | |||
than adequate performance, two. Based on these numbers, the finding was | |||
characterized by the SDP as having very low safety significance (20 - 34% failure rate), | |||
or Green. The finding is of very low safety significance because the failures occurred | |||
during annual testing of the operators on the simulator, because there were no actual | |||
consequences to the failures, because the crews were removed from watch standing | |||
duties, retrained, and re-evaluated before they were authorized to return to control room | |||
watches, and because the crew failure rate for the 2005 Unit 2 Annual Operating Exams | |||
was less than 20%. | |||
Enforcement. NRC regulations require that licensed operators pass an annual | |||
operating test; the regulations do not specify pass/fail rates. When a failure occurs, | |||
requirements are met by restricting the operator from licensed duties until the operator | |||
has been retrained and successfully retested, steps which licensee staff completed. | |||
Therefore, no violation of regulatory requirements occurred. Crew performance on the | |||
2006 annual operating exams has been entered into the corrective action program | |||
(CAP) as CR 2006-5797, and Constellation performed a level 1 root cause analysis of | |||
these crew failures. (FIN 05000410/2006011-04, Unit 2 Crew Failure Rate on the | |||
Dynamic Simulator Portion of the Annual Operating Examinations) | |||
4. OTHER ACTIVITIES (OA) | |||
Enclosure | |||
13 | |||
4OA5 Other | |||
1. Acceptability or Suitability of Nine Mile Point Unit 1 and Unit 2 Simulator Scenario- | |||
Based-Tests (SBTs) For Meeting ANSI/ANS-3.5-1998 Performance Testing Criteria | |||
The inspectors reviewed actions taken by Constellation since this item was opened | |||
during a 2004 Licensed Operator Requalification Program inspection and determined | |||
that this item will remain open pending further NRC review (i.e., the NRC has not | |||
reached final resolution with the industry regarding an acceptable level of test | |||
documentation to support this approach). (URI 05000220&410/2004005-03, | |||
Acceptability or Suitability of Nine Mile Point Unit 1 and Unit 2 Simulator Scenario- | |||
Based-Tests (SBTs) For Meeting ANSI/ANS-3.5-1998 Performance Testing Criteria) | |||
4OA6 Meetings, including Exit | |||
The lead inspector and the NRC Region I Operations Branch Chief presented the | |||
inspection results to members of licensee management team in an onsite meeting at the | |||
conclusion of the inspection on January 18, 2007. No materials reviewed were | |||
identified by the licensee as proprietary. | |||
Enclosure | |||
A-1 | |||
ATTACHMENT | |||
SUPPLEMENTAL INFORMATION | |||
KEY POINTS OF CONTACT | |||
Licensee Personnel | |||
T. OConnor, Site Vice President/Plant General Manager | |||
M. Schimmel, Plant General Manager | |||
N. Conicella, Operations Manager | N. Conicella, Operations Manager | ||
T. Shortell, Training Manager | T. Shortell, Training Manager | ||
Line 619: | Line 899: | ||
D. Kelly, Requal Exam Developer | D. Kelly, Requal Exam Developer | ||
G. Bobka, Operations Training | G. Bobka, Operations Training | ||
W. Coppom, Operations | W. Coppom, Operations Training | ||
NRC Personnel | |||
L. Cline, Senior Resident Inspector | |||
E. Knutson, Resident Inspector | |||
J. Caruso, Senior Operations Examiner/Inspector | J. Caruso, Senior Operations Examiner/Inspector | ||
P. Presby, Operations Examiner/Inspector | P. Presby, Operations Examiner/Inspector | ||
R. McKinley, Operations Examiner/Inspector (UI) | R. McKinley, Operations Examiner/Inspector (UI) | ||
J. Sullivan, Operations Examiner/Inspector (UI)LIST OF ITEMS OPENED, CLOSED, AND | J. Sullivan, Operations Examiner/Inspector (UI) | ||
A- | LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED | ||
Opened | |||
Meeting ANSI/ANS-3.5-1998 Performance Testing | 05000220/2006011-01 AV Failure to Ensure Integrity of Unit 1 Examinations and | ||
:TAP-TQS-04 NMP Examination Standard Rev. | Tests (Section 1R11.1) | ||
05000410/2006011-02 NCV Failure to Ensure Integrity of Unit 2 Examinations and | |||
Tests (Section 1R11.2) | |||
05000220/2006011-03 FIN Unit 1 Crew Failure Rate on the Dynamic Simulator Portion | |||
of the Annual Operating Examinations (Section 1R11.3) | |||
Attachment | |||
A-2 | |||
05000410/2006011-04 FIN Unit 2 Crew Failure Rate on the Dynamic Simulator Portion | |||
of the Annual Operating Examinations (Section 1R11.4) | |||
Discussed | |||
05000220&410/2004005-03 URI Acceptability or Suitability of Nine Mile Point Unit 1 and | |||
Unit 2 Simulator Scenario-Based-Tests (SBTs) For | |||
Meeting ANSI/ANS-3.5-1998 Performance Testing Criteria | |||
LIST OF DOCUMENTS REVIEWED | |||
Procedures: | |||
TAP-TQS-04 NMP Examination Standard Rev. 07 | |||
NTP-TQS-102 Licensed Operator Requalification Training Rev. 35 | |||
NTP-TQS-400 Instructions for Completing and Processing NRC Forms 396 and 398 Rev. 18 | NTP-TQS-400 Instructions for Completing and Processing NRC Forms 396 and 398 Rev. 18 | ||
S-FFD-16 Fitness for Duty Procedure Rev. 04 | S-FFD-16 Fitness for Duty Procedure Rev. 04 | ||
S-ODP-TQS-0101 Administrative Controls for Maintaining Active License Status at NMP Rev. | S-ODP-TQS-0101 Administrative Controls for Maintaining Active License Status at NMP Rev. | ||
04 | 04 | ||
GAI-OPS-13 Operations Score Card Program Rev. 03 | GAI-OPS-13 Operations Score Card Program Rev. 03 | ||
Line 640: | Line 939: | ||
NMP-TR-1.01-50 Evaluation Phase Activities Rev. 0 | NMP-TR-1.01-50 Evaluation Phase Activities Rev. 0 | ||
NMP-TR-1.01-60 Simulator Operation & Testing Rev. 0 | NMP-TR-1.01-60 Simulator Operation & Testing Rev. 0 | ||
NMP-TR-1.01-70 Training Administration Rev. | NMP-TR-1.01-70 Training Administration Rev. 0 | ||
Requalification Exam Compromise | Other: | ||
CR-NM-2006-4808 | |||
Category I Root Cause Analysis (CR-NM-2006-4808), Annual Licensed Operator | |||
Requalification Exam Compromise | |||
NMP1 2006 Biennial Exam Sample Plan | NMP1 2006 Biennial Exam Sample Plan | ||
NMP1 Biennial Schedule 05/06 Rev.1 | NMP1 Biennial Schedule 05/06 Rev.1 | ||
NMP1 Independent Self-Assessment Report, Assessment #: FSA-2006-43 Scenarios:*O1-OPS-009-1-DY-71 rev. 0 AWTS w/ Main Condenser | NMP1 Independent Self-Assessment Report, Assessment #: FSA-2006-43 | ||
*O1-OPS-009-1-DY-63 rev. 0 AWTS w/ Main Condenser | Scenarios: | ||
*O1-OPS-009-1-DY-05 rev. 4 AWTS w/o Main Condenser | * O1-OPS-009-1-DY-71 rev. 0 AWTS w/ Main Condenser | ||
*O1-OPS-009-1-DY-11 rev. 4 AWTS w/o Main Condenser | * O1-OPS-009-1-DY-63 rev. 0 AWTS w/ Main Condenser | ||
*O1-OPS-009-1-DY-17 rev. 2 AWTS w/o Main Condenser | * O1-OPS-009-1-DY-05 rev. 4 AWTS w/o Main Condenser | ||
*O1-OPS-009-1-DY-18 rev. 8 AWTS w/ Main Condenser | * O1-OPS-009-1-DY-11 rev. 4 AWTS w/o Main Condenser | ||
*O1-OPS-009-1-DY-25 rev. 6 Steam Leak in Drywell w/ blowdown | * O1-OPS-009-1-DY-17 rev. 2 AWTS w/o Main Condenser | ||
*O1-OPS-009-1-DY-39 rev. 6 Steam Leak in Drywell | * O1-OPS-009-1-DY-18 rev. 8 AWTS w/ Main Condenser | ||
* O1-OPS-009-1-DY-25 rev. 6 Steam Leak in Drywell w/ blowdown | |||
* O1-OPS-009-1-DY-39 rev. 6 Steam Leak in Drywell | |||
Attachment | |||
A-3 | |||
Open Simulator Deficiency Reports (DRs)Scheduled Simulator Enhancements | * O1-OPS-009-1-DY-48 rev. 4 AWTS w/ Main Condenser | ||
Simulator Training Load Acceptance Reports- June to August 2006 | * O1-OPS-009-1-DY-50 rev. 2 AWTS w/ Main Condenser and Torus Leak | ||
- Dec. 2005 to March 2006 | * O1-OPS-009-1-DY-53 rev. 3 Steam Leak in Drywell | ||
- Sept. to Dec. 2005 | * O1-OPS-009-1-DY-54 rev. 3 AWTS w/o Main Condenser | ||
- July to Sept. | * O1-OPS-009-1-DY-55 rev. 1 AWTS w/ Main Condenser | ||
Open Simulator Deficiency Reports (DRs) | |||
Scheduled Simulator Enhancements | |||
Simulator Training Load Acceptance Reports | |||
- June to August 2006 | |||
- Dec. 2005 to March 2006 | |||
- Sept. to Dec. 2005 | |||
- July to Sept. 2005 | |||
Simulator Exceptions List | |||
Simulator Four Year Test Schedule | Simulator Four Year Test Schedule | ||
Simulator Configuration Control Board (SCCB) Meeting Minutes:- October 19, 2005 | Simulator Configuration Control Board (SCCB) Meeting Minutes: | ||
- August 4, 2006 | - October 19, 2005 | ||
- July 14, | - August 4, 2006 | ||
- DR 3538 | - July 14, 2006 | ||
- Upgrade DR | Simulator Documents related to Jan 2004 Emer Cooling Test (NCV05000220/2004005-02) | ||
- DR 3799, Offgas Controller | - DR 3531 | ||
- DR 3798, RWCU Conductivity | - DR 3538 | ||
- DR 3797, Indicator Should Read Downscale | - Upgrade DR 80 | ||
- DR 3789, Safety Valve Outlet High Temperature | 2005 Simulator Model Test, ANSI 3.5 Appendix "B" B1.2(3) Simultaneous Closure of All MSIVs | ||
- DR 3782, Pressure Oscillation with TC05 Initiated | Simulator Deficiency Reports | ||
- DR 3760, Malfunctions FW29A&B Do Not Work | - DR 3884, Recirc Pump Metering | ||
- Upgrade DR 165, Change Sim Status Hi Press | - DR 3799, Offgas Controller | ||
- CR-NM-2005-615, NRC Identified URI on Suitability of | - DR 3798, RWCU Conductivity | ||
- DR 3797, Indicator Should Read Downscale | |||
- DR 3789, Safety Valve Outlet High Temperature | |||
- DR 3782, Pressure Oscillation with TC05 Initiated | |||
- DR 3760, Malfunctions FW29A&B Do Not Work | |||
- Upgrade DR 165, Change Sim Status Hi Press Setting | |||
Condition Reports Related to Simulator | |||
- CR-NM-2005-542, NRC Identified Green NCV | |||
- CR-NM-2005-615, NRC Identified URI on Suitability of SBTs | |||
Simulator Scenario Based Tests for Cycle C09 and Cycle 10 (2006) | |||
Simulator vs. Plant Comparison for Stuck Open ERV | Simulator vs. Plant Comparison for Stuck Open ERV | ||
Simulator vs. Plant Comparison for 8/3/04 Feedwater Spiking, Manual Scram | Simulator vs. Plant Comparison for 8/3/04 Feedwater Spiking, Manual Scram | ||
2005 Simulator Steady State Comparisons at 40%, 75% and 100% | 2005 Simulator Steady State Comparisons at 40%, 75% and 100% | ||
Attachment | |||
}} | }} |
Latest revision as of 09:30, 23 November 2019
ML070440231 | |
Person / Time | |
---|---|
Site: | Nine Mile Point |
Issue date: | 02/13/2007 |
From: | Blough A Division of Reactor Safety I |
To: | O'Connor T Nine Mile Point |
Shared Package | |
ML053400259 | List: |
References | |
EA-07-001 IR-06-011 | |
Download: ML070440231 (26) | |
See also: IR 05000220/2006011
Text
February 13, 2007
Mr. Timothy J. OConnor
Vice President Nine Mile Point
Nine Mile Point Nuclear Station, LLC
P.O. Box 63
Lycoming, NY 13093
SUBJECT: NRC LICENSED OPERATOR REQUALIFICATION PROGRAM INSPECTION
REPORT 05000220/2006011 AND 05000410/2006011;
PRELIMINARY WHITE FINDING - NINE MILE POINT NUCLEAR STATION
Dear Mr. OConnor:
During the period October 16, 2006 through January 9, 2007, the US Nuclear Regulatory
Commission (NRC) conducted an inspection of the Nine Mile Point Nuclear Station Licensed
Operator Requalification Program activities. The enclosed report documents the inspection
findings, which were discussed on January 18, 2007 in an onsite exit meeting with you and
members of your staff.
The inspection examined activities conducted under your license as they relate to safety and
compliance with the Commissions rules and regulations and with the conditions of your license.
The inspectors reviewed selected procedures and records, observed activities, and interviewed
personnel. The inspection consisted of a review of the licensed operator requalification
program. Findings identified during the inspection are discussed in detail in the enclosed
inspection report.
This report documents a preliminary White finding that appears to have low to moderate safety
significance. As described in Section 1.R11 of this report, your Licensed Operator
Requalification Training Program allowed operating crews to validate simulator exam scenarios
that were substantially the same as those that were later administered to these crews as part of
their annual operating test. This shortcoming had the unintentional effect of compromising
your Unit 1 2005 and 2006 dynamic simulator exam scenarios. The apparent compromise of
the 2005 Unit 1 simulator exam scenarios is considered more serious and the basis for the
preliminary White finding since the apparent compromise was not corrected by Constellation
prior to returning licensed operators to normal duties. In contrast, for the 2006 exam
compromise problems Constellation took remedial actions by retesting all operators prior to the
end of the exam cycle. This finding was assessed using the Operator Requalification Human
Performance Significance Determination Process as a potentially safety significant finding that
was preliminarily determined to be White; i.e., a finding with some increased importance to
safety, which may require additional NRC inspection. The issue has a low to moderate safety
significance because it represented a failure to recognize and correct an apparent examination
compromise of the 2005 Unit 1 simulator exam scenarios, and a subsequent return to normal
T. OConnor 2
watch-standing duties by the licensed operators without adequate compensatory actions for the
compromised examinations. This finding was not an immediate safety concern for the following
reasons: (1) there were no significant plant performance issues related to operator knowledge
and abilities; (2) all licensed operators had participated in a continuous requalification training
program; (3) this issue, while pervasive, was limited to the 2005 and 2006 exams and did not
extend to the 2004 exams; and (4) Constellation took immediate remedial actions by
invalidating the simulator exam scenario portion of the 2006 annual operating exams and
administering new and more comprehensive simulator exam scenarios to all licensed operators
upon discovery of this concern by the NRC.
The finding is also an apparent violation of NRC requirements and is being considered for
escalated enforcement action in accordance with the Enforcement Policy, which can be found
on the NRCs web site at http://www.nrc.gov/reading-rm/adams.html.
Before we make a final decision regarding the preliminary White finding, we are providing you
an opportunity (1) to attend a Regulatory Conference where you can present to the NRC your
perspective on the facts and assumptions the NRC used to arrive at the finding and assess its
significance, or (2) submit your position on the finding to the NRC in writing. If you request a
Regulatory Conference, it should be held within 30 days of the receipt of this letter and we
encourage you to submit supporting documentation at least one week prior to the conference in
an effort to make the conference more efficient and effective. If a Regulatory Conference is
held, it will be open for public observation. If you decide to submit only a written response, such
submittal should be sent to the NRC within 30 days of the receipt of this letter.
Please contact Mr. Marvin Sykes at (610) 337-5046 within 10 business days of the date of your
receipt of this letter to notify the NRC of your intentions. If we have not heard from you within
10 days, we will continue with our significance determination and enforcement decision and you
will be advised by separate correspondence of the results of our deliberations on this matter.
Since the NRC has not made a final determination in this matter, no Notice of Violation is being
issued for this inspection preliminary White finding at this time. In addition, please be advised
that the number and characterization of the apparent violation described in the enclosed
inspection report may change as a result of further NRC review.
In addition, the report documents three NRC-identified findings of very low safety significance
(Green). One of these findings was determined to involve a Unit 2 violation of NRC
requirements involving similar but less significant exam compromise issues to those identified
for Unit 1 for reasons detailed in the enclosed report. The unintentional 2006 Unit 2 simulator
exam scenario compromise was assessed separately due to Unit 1 and 2 plant design
differences that require unique training programs for each unit, as well as unique plant and
operator licenses. However, because of the very low safety significance and because it is
entered into your corrective action program, the NRC is treating the Unit 2 exam compromise
finding as a non-cited violation (NCV) consistent with Section VI.A.1 of the NRC Enforcement
Policy. If you contest this NCV, you should provide a response within 30 days of the date of
this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission,
ATTN: Document Control Desk, Washington DC 20555-0001; with copies to the Regional
Administrator, Region I; the Director, Office of Enforcement, United States Nuclear Regulatory
Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at Nine Mile Point
Nuclear Station.
T. OConnor 3
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its
enclosure will be available electronically for public inspection in the NRC Public Document
Room or from the NRCs document system (ADAMS), accessible from the NRC Web site at
http://www.nrc.gov/reading-rm/adams.html.
Sincerely,
/RA/
A. Randolph Blough, Director
Division of Reactor Safety
Docket No: 50-220, 50-410
Enclosure: Inspection Report 05000220/2006011 and 05000410/2006011
T. OConnor 4
cc w/encl:
M. J. Wallace, President, Constellation Generation
M. Heffley, Senior Vice President and Chief Nuclear Officer
C. W. Fleming, Esquire, Senior Counsel, Constellation Energy Group, LLC
M. J. Wetterhahn, Esquire, Winston and Strawn
P. Smith, President, New York State Energy, Research, and Development Authority
J. Spath, Program Director, New York State Energy Research and Development Authority
P. D. Eddy, Electric Division, NYS Department of Public Service
C. Donaldson, Esquire, Assistant Attorney General, New York Department of Law
Supervisor, Town of Scriba
T. Judson, Central NY Citizens Awareness Network
D. Katz, Citizens Awareness Network
T. Shortell, Manager, Nuclear Training
S. Glenn, INPO
T. OConnor 5
Distribution w/encl:
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OEWEB
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B Jones, OGC
M Elwood, OGC
J Dyer, NRR
M Weber, NRR
B Boger, NRR
M. David, NRR
J Lamb, OEDO
S Collins, RA
M Dapas, DRA
Enforcement Coordinators RII, RIII, RIV
E Hayden, OPA
H Bell, OIG
G Caputo, OI
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Region I OE Files (with concurrences)
A. R. Blough, DRS
J. Caruso, Chief Examiner, DRS
E. Knutson, RI - NMP
K. Kolek, OA - NMP
DRS Master Exam File ©. Bixler (w/concurrences)
DRS File
T. OConnor 6
C:\FileNet\ML070440231.wpd
SUNSI Review Complete: JGC (Reviewers Initials)
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After declaring this document An Official Agency Record it will be released to the Public.
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OFFICE RI/DRS RI/DRS RI/DRS RI/ORA RI/DRS
NAME JCaruso/JGC MSykes/MDS BMcDermott/BJM RSummers/RJS WSchmidt/WLS
DATE 02/05/07 02/05/07 02/07/07 02/06/07 02/06/07
OFFICE RI/DRS
NAME ABlough/ARB
DATE 02/13/07
OFFICIAL RECORD COPY
U.S. NUCLEAR REGULATORY COMMISSION
REGION I
Docket No: 50-220, 50-410
Report Nos: 05000220/2006011, 05000410/2006011
Licensee: Nine Mile Point Nuclear Station, LLC (NMPNS)
Facility: Nine Mile Point, Units 1 and 2
Location: Lake Road
Oswego, NY
Dates: October 16, 2006 - January 9, 2007
Inspectors: J. Caruso, Senior Operations Engineer
P. Presby, Operations Engineer
R. McKinley, Operations Engineer (under-instruction)
J. Sullivan, Operations Engineer (under-instruction)
Approved by: Marvin D. Sykes, Chief
Operations Branch
Division of Reactor Safety
SUMMARY OF FINDINGS
IR 05000220/2006-011, 05000410/2006-011; 10/16/06 - 1/09/07; Nine Mile Point, Units 1 and
2; Licensed Operator Requalification Program, Inspection Procedure Attachment 71111.11.
This inspection was conducted by two NRC region-based inspectors and two inspectors under
instruction. Three Green findings and one Apparent Violation (AV) with potential safety
significance greater than Green, were identified. The significance of most findings is indicated
by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609,
Significance Determination Process (SDP). Findings for which the SDP does not apply may
be Green or be assigned a severity level after NRC management review. The NRCs program
for overseeing the safe operation of commercial nuclear power reactors is described in
NUREG-1649, Reactor Oversight Process, Revision 3, dated July 2000.
A. NRC-Identified and Self-Revealing Findings
Cornerstone: Mitigating Systems
- TBD. An apparent violation of 10 CFR 55.49, Integrity of Examinations and
Tests, was identified, concerning an apparent compromise of the 2005 and the
2006 annual operating exams at Unit 1. NRC inspectors identified practices that
collectively had the impact of compromising, albeit unintentionally, the
examinations; these practices included: 1) a lack of simulator exam scenario
diversity (i.e., The scenarios were substantially the same including: critical tasks;
major transients; Emergency Operating Procedure flow paths; and emergency
classifications); 2) an overuse of a single emergency operating procedure
strategy (i.e., full core Anticipated Transient Without Scram); and 3) a pattern of
crews validating scenarios substantially similar to their exam scenario sets.
Constellation had not identified and compensated for the compromise prior to
completing the 2005 exam and returning the operators to normal control room
duties. Following NRC identification of the compromise in 2006, Constellation
took immediate and substantive corrective actions prior to completion of the
annual operating exam cycle. Based on the Licensed Operator Requalification
Significance Determination Process (SDP) this finding was preliminarily
determined to be of low to moderate safety significance (White). The licensee
initiated Condition Report CR-NM-2006-4808, dated October 19, 2006, that
documented this issue and later initiated a Category I Root Cause Analysis (CR-
NM-2006-4808), Annual Licensed Operator Requalification Exam Compromise.
This finding was more than minor because it was associated with the Human
Performance attribute of the Initiating Events, Mitigation Systems, and Barrier
Integrity cornerstones and affected the combined objective of: limiting the
likelihood of; ensuring the availability and reliability of mitigating systems to
respond to; and providing reasonable assurance that physical barriers protect
the public from radio-nuclide releases caused by, initiating events.
The finding has a cross-cutting aspect in the area of problem identification and
resolution because Constellation did not effectively collect, evaluate, and
ii Enclosure
communicate applicable external operating experience to affected internal
stakeholders nor did they conduct self-assessments that were comprehensive,
appropriately objective, and self-critical such that either Unit 1 2005 exam
compromise issues were avoided altogether or identified and corrected prior to
the end of the 2005 annual operating exam cycle. (Section 1R11.1)
- Green. A Green NRC-identified non-cited violation (NCV) of 10CFR55.49 was
identified, concerning an apparent compromise of the 2006 annual operating
requalification examinations at Unit 2. NRC inspectors identified practices that
collectively had the impact of compromising, albeit unintentionally; the
examinations, these practices included: 1) a lack of simulator exam scenario
diversity (i.e., The scenarios were substantially the same including: critical tasks;
major transients; Emergency Operating Procedure flow paths; and emergency
classifications); 2) an overuse of a single emergency operating procedure
strategy (i.e., full core Anticipated Transient Without Scram); and 3) a pattern of
crews validating scenarios substantially similar to their exam scenario sets. The
licensee initiated CR-NM-2006-4808 that documented this concern and later
initiated a Category I Root Cause Analysis.
This finding was more than minor because it was associated with the Human
Performance attribute of the Initiating Events, Mitigation Systems, and Barrier
Integrity cornerstones and affected the combined objective of: limiting the
likelihood of; ensuring the availability and reliability of mitigating systems to
respond to; and providing reasonable assurance that physical barriers protect
the public from radio nuclide releases caused by, initiating events. The finding
was assessed as having very low safety significance because immediate and
substantive corrective actions were taken by Constellation prior to the end of the
current exam cycle.
The finding has a cross-cutting aspect in the area of problem identification and
resolution because Constellation did not effectively collect, evaluate, and
communicate applicable external operating experience to affected internal
stakeholders nor did they conduct self-assessments that were comprehensive,
appropriately objective, and self-critical such that the 2006 Unit 2 exam
compromise issues were either avoided altogether or at least identified and
corrected by Constellation prior to the start of this inspection. (Section 1R11.2)
- Green. A finding of very low safety significance was identified at Unit 1. The
finding was associated with crew performance on the simulator during the 2006
facility-administered requalification examinations. Of the six crews evaluated,
two failed to pass their simulator examinations when the newly developed more
comprehensive exams were re-administered in response to the above noted
preliminary White finding. The failures are documented in licensee-initiated
Condition Report CR 2006-5797, which resulted in Constellation conducting a
Category I Root Cause Analysis.
This finding was more than minor because it was associated with the Human
Performance attribute of the Initiating Events, Mitigation Systems, and Barrier
Integrity cornerstones and affected the combined objective of: limiting the
iii Enclosure
likelihood of; ensuring the availability and reliability of mitigating systems to
respond to; and providing reasonable assurance that physical barriers protect
the public from radio nuclide releases caused by, initiating events. The finding
was assessed as having very low safety significance because: 1) the failures
occurred during annual testing of the operators on the simulator; 2) there were
no actual consequences to the failures; 3) the crews were removed from watch
standing duties, retrained and re-evaluated before they were authorized to return
to control room watches; and, 4) because the crew failure rate for the 2005 Unit
1 Annual Operating Exams was less than 20%. (Section 1R11.3)
- Green. A finding of very low safety significance was identified at Unit 2. The
finding was associated with crew performance on the simulator during the 2006
facility-administered requalification examinations. Of the six crews evaluated,
two failed to pass their simulator examinations when the newly developed more
comprehensive exams were re-administered in response to the above noted
preliminary White finding. The failures are documented in licensee-initiated
Condition Report CR 2006-5797, which resulted in Constellation conducting a
Category I Root Cause Analysis.
This finding was more than minor because it was associated with the Human
Performance attribute of the Initiating Events, Mitigation Systems, and Barrier
Integrity cornerstones and affected the combined objective of: limiting the
likelihood of; ensuring the availability and reliability of mitigating systems to
respond to; and providing reasonable assurance that physical barriers protect
the public from radio nuclide releases caused by, initiating events. The finding
was assessed as having very low safety significance because: 1) the failures
occurred during annual testing of the operators on the simulator; 2) there were
no actual consequences to the failures; 3) the crews were removed from watch
standing duties, retrained and re-evaluated before they were authorized to return
to control room watches; and, 4) because the crew failure rate for the 2005 Unit
2 Annual Operating Exams was less than 20%. (Section 1R11.4)
B. Licensee-Identified Findings
None.
iv Enclosure
REPORT DETAILS
1. REACTOR SAFETY
1R11 Licensed Operator Requalification Program (71111.11)
a. Inspection Scope
The following inspection activities were performed using NUREG-1021, Rev. 9,
Operator Licensing Examination Standards for Power Reactors, Inspection Procedure
Attachment 71111.11, Licensed Operator Requalification Program, and NRC Manual
Chapter 0609, Appendix I, Operator Requalification Human Performance Significance
Determination Process (SDP), as acceptance criteria.
During the first onsite inspection week of October 16, 2006, inspectors observed
administration of licensed operator requalification exams on Unit 1, including two
dynamic simulator scenarios, three simulator Job Performance Measures (JPMs) and
two in plant JPMs for one operations crew. Following an NRC debrief on the preliminary
inspection issues identified, the licensee invalidated all of the dynamic simulator exams
for 2006 on both units and initiated development of new 2006 exam scenarios (see
Findings section of this report for further details). As a result of these identified issues
the scope of this inspection was expanded. During the weeks of November 20,
December 4 and December 11, 2006, the inspectors observed and assessed
Constellations administration of newly developed exam scenarios to all six of the Unit 1
operating crews and two of the Unit 2 operating crews. In addition, the inspectors
observed the administration of retake exam scenarios for one Unit 1 and one Unit 2
operating crew following their exam failures and subsequent training remediations.
The inspectors reviewed all three Unit 1 exam sets for both the comprehensive Reactor
Operator (RO) and Senior Reactor Operator (SRO) biennial written exams, as well as all
the newly developed simulator exam scenarios for both Unit 1 and 2, and a sample (i.e.,
exam weeks 1, 3, 4) of the Unit 1 JPMs administered during this current exam cycle to
ensure the quality of these exams met or exceeded the criteria established in the
Examination Standards and 10 CFR 55.59. In addition, both the Unit 1and 2 simulator
exam scenarios administered as part of the 2005 annual operating exams were
reviewed and evaluated as part of an exam compromise extent of condition review.
Simulator performance was evaluated through observation during the conduct of the
examinations, a review of simulator performance tests (e.g., steady state performance
tests, selected transient tests, and selected scenario-based tests), and a review of
Simulator Deficiency Reports to verify compliance with the requirements of 10 CFR
55.46 and guidance contained in ANSI/ANS-3.5-1998. Corrective actions were
reviewed associated with NCV 2004005-02 (Failure of NMP Simulator to Demonstrate
Expected Plant Response). No significant simulator issues were identified (see
document list attached).
Enclosure
2
The inspectors reviewed documentation of operating history since the last requalification
program inspection. The inspectors also discussed facility operating events with the
resident staff. Documents reviewed included NRC inspection reports, Plant
Performance Insights, licensee event reports (LERs), and licensee condition reports
(CRs) that involved human performance issues for licensed operators to ensure that
operational events were not indicative of possible training deficiencies.
The following record reviews were conducted: remediation plans for seven cyclic written
exam failures and one evaluated Operating Exam segment; seven medical records;
eight quarters of time on shift records; and, ten operator license reactivations.
On January 9, 2007, the inspectors conducted an in-office review of the full
requalification exam results to assess whether pass rates were consistent with the
guidance of NRC Manual Chapter 0609, Appendix I, Operator Requalification Human
Performance Significance Determination Process (SDP). Results are listed below.
Unit 1 Results:
- Crew failure rate on the dynamic simulator was less than 34%. The threshold for
a Green finding is a failure rate between 20% and 33%.
(Failure rate was 33.33%.)
- Individual failure rate on the dynamic simulator test was less than or equal to
20%. (Failure rate was 19.0%.)
- Individual failure rate on the walk-through test (JPMs) was less than or equal to
20%. (Failure rate was 2.4%.)
- Individual failure rate on the comprehensive biennial written exam was less than
or equal to 20%. (Failure rate was 2.4%)
- More than 75% of the individuals passed all portions of the exam (78.5% of the
individuals passed all portions of the exam).
Unit 2 Results:
- Crew failure rate on the dynamic simulator was less than 34%. The threshold for
a Green finding is a failure rate between 20% and 33%.
(Failure rate was 33.33%.)
- Individual failure rate on the dynamic simulator test was less than or equal to
20%. (Failure rate was 12.5%.)
- Individual failure rate on the walk-through test (JPMs) was less than or equal to
20%. (Failure rate was 0.0%.)
Enclosure
3
- Individual failure rate on the comprehensive biennial written exam was less than
or equal to 20%. (Not applicable - not administered this year)
- More than 75% of the individuals passed all portions of the exam (87.2% of the
individuals passed all portions of the exam).
b. Findings
1. Failure to Ensure Integrity of Unit 1 Examinations and Tests
Introduction. An apparent violation of 10 CFR 55.49, Integrity of Examinations and
Tests, was identified, concerning an apparent compromise of the 2005 and the 2006
annual operating exams at Unit 1. Constellation had not identified and compensated for
the compromise prior to completing the 2005 exam and returning the operators to
normal control room duties. Following NRC identification of the compromise in 2006,
Constellation took immediate and substantive corrective actions prior to completion of
the annual and biennial operating exam cycles. Based on the Licensed Operator
Requalification Significance Determination Process (SDP) this was preliminarily of low to
moderate safety significance (White).
Description. The inspectors identified that the exam practices used by Constellation at
Nine Mile Point resulted in an apparent compromise of the simulator exam scenario
portion of both the 2005 and 2006 annual operating tests. The apparent compromise is
considered widespread, because all licensed operator requalification crews were
affected on both the 2005 and 2006 exams. The apparent compromise of the 2005
Unit 1 simulator exam scenarios is considered more serious than the 2006 exam
compromises and the basis for the preliminary White finding since the 2005 apparent
exam compromises were not corrected by the licensee prior to returning licensed
operators to normal watch-standing duties. In contrast, in 2006 when the exam
compromises were identified by the NRC and brought to the attention of Constellation
remedial actions were taken to retest all of the operators prior to the end of the exam
cycle.
The issue was identified while conducting the Unit 1 biennial Licensed Operator
Requalification Training (LORT) Program inspection during the week of October 16,
2006. Constellation allowed operating crews to validate simulator exam scenarios that
were substantially the same as the simulator exam scenarios that were later
administered to these crews as part of their annual operating test, thus preconditioning
the operators. These practices did not comply with Constellations procedural guidance,
NMP-TR-1.01-20, Attachment 5, Section B.2 states, Personnel shall not validate any
materials to be used on their exams, and Section D stipulates each section of the
requalification exams will contain at least 50% new material.
Enclosure
4
The inspectors identified that the scenarios validated by Unit 1 A crew (September 12-
16, 2006) were substantially similar in content to the two simulator exam scenarios that
were administered to A crew on October 17, 2006. With the exception of a few
malfunctions, the scenarios were substantially the same, i.e., the same critical tasks,
major transients, Emergency Operating Procedure (EOP) flow paths, and emergency
classifications. In addition, on October 16, 2006, one day before taking their annual
operating test using scenario #4, A crew was administered exam scenario #2 for
validation/practice. The inspectors determined that scenario #2 was substantially the
same as scenario #4. The inspectors determined that the other crews examined during
the first three weeks of the exam cycle had also validated scenarios that were
substantially similar in content to the simulator exam scenarios administered during their
exam weeks.
The inspection team further noted that twelve of the sixteen new simulator exam
scenarios developed for the Unit 1 2006 annual operating test cycle involved a full core
Anticipated Transient Without Scram (ATWS) theme and varied primarily by changing
several malfunctions for each scenario. This lack of exam diversity, an overuse of the
ATWS theme, and a pattern of crews validating scenarios substantially similar to their
exam scenario sets collectively had the effect of compromising the exams. In addition,
the over-emphasis on examining the ATWS theme resulted in not testing other
important EOP mitigation strategies (e.g., secondary containment and radiation release
strategies). Furthermore, the inspectors determined that the scenario exam sets
previously administered during weeks 1 and 2 were scheduled to be re-administered
during exam weeks 5 and 6 respectively.
The NRC inspection team communicated these issues to Constellation representatives.
On October 20, 2006, representatives of Constellation management agreed with the
NRC inspection teams assessment of the issues. Constellation determined that the
2006 Unit 1 and 2 annual license simulator exam scenarios administered to date were
invalid due to the pervasive nature of the apparent exam compromise. Exam
administration was suspended at both units pending development of new exams. The
licensee initiated Condition Report CR-NM-2006-4808, dated October 19, 2006 that
documented this issue and later initiated a Category I Root Cause Analysis (CR-NM-
2006-4808), Annual Licensed Operator Requalification Exam Compromise. Note: A
Category I Root Cause Analysis is conducted by independent parties, involves a
thorough investigation of the details that led to the problem, identifies the root as well as
contributing causes, and assigns corrective actions to prevent re-occurrence of the
problem.
Following the onsite visit, the NRC inspection team conducted an in-office extent of
condition review of the Unit 1 2005 simulator exam scenario portion of the annual
operating tests. The team determined that the 2005 simulator exam scenarios were
compromised and this problem went undetected and uncorrected by the licensee. The
problem remained undetected until it was identified by the NRC and brought to the
attention of Constellation. The problems with the 2005 simulator exam scenarios were
similar to those identified on the 2006 dynamic exams and included a lack of exam
diversity, an overuse of the ATWS theme (8 of 11 scenarios), and a pattern of crews
Enclosure
5
validating scenarios that were substantially similar to their exam scenario sets. In
contrast to the 2006 exam, the compromise to the simulator scenario exam portion of
2005 annual operating test was undetected and uncorrected, led to licensed operators
returning to normal watch-standing duties without adequate compensatory actions being
taken and therefore, is the basis for the preliminary White finding.
Inspectors conducted interviews with the exam development team and reviewed
associated development records for the 2005 and 2006 exams. Based on this review, it
appeared that the exam compromise issue resulted from NMP staff inexperience and
lack of management oversight of the exam development process. Constellations
emphasis on maintaining exam security resulted in self-imposed restrictions on
management oversight of the exam development process. In addition, the exam
development team operated under some misconceptions including: 1) due to a recent
upgrade to the simulator model, rather than modifying existing exam scenarios, the
exam team needed to draft all new simulator exam scenarios; 2) all revisions to exam
scenarios had to be validated by an operating crew which, in some cases, resulted in
multiple crew exposures to a single scenario; 3) minor revisions to an exam scenario
were enough to consider the scenario sufficiently unique to be considered a new
scenario; 4) it is acceptable for a crew to validate a simulator exam scenario
substantially the same as their exam scenario, provided this is done six weeks in
advance; and 5) each exam had to include events which challenged one or more critical
tasks from a small pre-existing list of critical tasks which did not encompass the full
range of major events. These misconceptions resulted in a narrowly focused exam
which over-tested the ATWS theme at the exclusion of other equally important EOP
mitigation strategies. The inspectors did not find any indication that the compromises
were intentional.
The licensees root cause team later concluded, ...that similarities in the scenarios in
the 2006 Unit 1 exam set caused unintentional preconditioning of the crew by exposing
them to scenarios during validation that were essentially the same as the scenarios
used for their exam ... and reviewed the 2005 Unit 1 exam sets and found issues similar
to those associated with the 2006 Unit 1 exam. The root cause team identified two
primary causes: 1) policy guidance, management expectations, and job performance
standards were not well-defined or understood, the process provides minimal direction
and guidance, which the inexperienced team was not able to compensate for through
their knowledge; and 2) a rigorous review and analysis of the exam by an experienced
exam author did not occur during the review/challenge process. No one outside the
immediate exam development team performed a comprehensive exam set review.
New and more comprehensive simulator scenario exams were developed and
administered to all licensed operators between November 20 and December 14, 2006.
The inspection team observed the re-testing of all Unit 1 licensed operators and noted
the following improvements: 1) development and administration of new, more
comprehensive simulator exam scenarios; 2) one-on-one operator evaluations; 3)
rotating watch positions for the SROs as well as the ROs between scenarios; 4)
evaluation of Shift Technical Advisor position; and 5) conducting more detailed post
exam critiques.
Enclosure
6
Analysis. The unintentional integrity comprise of the simulator exam scenario portion of
the Unit 1 2005 and 2006 annual operating exams was a performance deficiency, in that
Constellation failed to follow their established requalification procedures and resulted in
an apparent violation of 10 CFR 55.49. Integrity of Exams and Tests. Specifically, in
2005 and initially in 2006 the operators were tested using requalification simulator exam
scenarios substantially similar to simulator exam scenarios that they had previously
validated. Therefore, the validation process, in combination with a lack of exam
diversity, caused exam integrity to be compromised. Traditional enforcement does not
apply because the issue did not have any actual safety consequences, potential for
impacting the NRCs regulatory function, and was not the result of any willful violation of
NRC requirements or Constellations procedures. This finding was more than minor
because it was associated with the Human Performance attribute of the Initiating
Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the
combined objective of: limiting the likelihood of; ensuring the availability and reliability of
mitigating systems to respond to; and providing reasonable assurance that physical
barriers protect the public from radio nuclide releases caused by, initiating events.
This finding was determined preliminarily to have low to moderate safety significance
(White) using the Licensed Operator Requalification Human Performance Significance
Determination Process (SDP) Inspection Manual Chapter 0609, Appendix I. Block 21
applies, Has the integrity of the scenario been compromised? This is a failure to
control the scenario identity or material including the validation process such that the
operating test integrity is affected. The answer to the Block 21 question is yes, the
operators were tested using requalification exam scenarios substantially similar to exam
scenarios that they had previously validated. Therefore, the validation process, in
combination with a lack of scenario diversity, led to an unintentional exam compromise.
Block 26 also applies, When the compromise was discovered, or should have been
discovered, did the licensee take immediate compensatory measures. The answer to
the Block 26 question is no, as Constellation did not identify and take immediate
corrective actions for the 2005 Unit 1 exam compromises (Block 21 - Yes and Block 26 -
No). This simulator exam scenario integrity compromise finding should have been
discovered and corrected by Constellation, prior to NRC identification. Constellation
should have discovered the problem in 2005 or at least prior to the NRCs identification
because: 1) a similar issue was described in 2002 Industry Operating Experience
involving exam compromise; 2) Constellation completed a self audit in August 2006 that
failed to identify this issue; and 3) the practices clearly violated NRC guidance and
requirements, as well as Constellations procedural guidance aimed at preventing exam
compromise. More importantly, however, in 2005, because the issue was not identified
at the time, Constellation had not taken compensatory actions prior to returning the
operators to normal control room duties. Following identification of this issue by the
NRC, the licensee took immediate and substantive corrective actions to remedy the
2006 annual operating exam compromise, by developing new exams and re-testing all
the Unit 1 licensed operators within the required annual and biennial exam cycles.
The cause of the finding has a cross-cutting aspect in the area of problem identification
and resolution in that Constellation did not effectively collect, evaluate, and
Enclosure
7
communicate applicable external operating experience to affected internal stakeholders
nor did they conduct self-assessments of sufficient depth that were comprehensive,
appropriately objective and self-critical such that the Unit 1 2005 exam compromise
issues were avoided altogether or at least identified and corrected prior to the end of the
2005 annual operating exam cycle.
Enforcement. 10 CFR 55.49, requires, in part, that, ...licensees shall not engage in any
activity that compromises the integrity of any application, test, or examination required
by this part. The integrity of a test or examination is considered compromised if any
activity, regardless of intent, affected, or, but for detection, would have affected the
equitable and consistent administration of the test or exam. Contrary to this
requirement, the Unit 1 2005 and 2006 annual operating tests were compromised since
the process used to validate the simulator exam scenarios resulted in licensed operators
being knowledgeable of a significant portion of the test prior to its administration.
This finding was not an immediate safety concern for the following reasons: 1) there
were no significant plant performance issues related to operator knowledge and
abilities; 2) all licensed operators had participated in a continuous requalification training
program; 3) this issue, while pervasive, was limited to the 2005 and 2006 exams and did
not extend to the 2004 exams; 4) Constellation took immediate remedial actions by
administering new and more comprehensive simulator exam scenarios to all Unit 1
licensed operators upon discovery of this concern by the NRC. Some individual and
crew weaknesses were identified, as evidenced by the individual and crew failure rates,
however the performance on these new exams was overall satisfactory. (AV 50-
220/2006011-01, Failure to Ensure Integrity of Unit 1 Examinations and Tests)
2. Failure to Ensure Integrity of Unit 2 Examinations and Tests
Introduction. A non-cited violation of 10 CFR 55.49, Integrity of Examinations and
Tests, was identified, concerning an apparent compromise of the 2006 annual
operating exams at Unit 2. Following NRC identification of the compromise,
Constellation took adequate compensatory measures, prior to completion of the annual
and biennial exam cycles.
Description. The inspectors identified that the exam practices used by Constellation at
Nine Mile Point resulted in an apparent compromise of the dynamic scenario portion
the 2006 annual operating tests.
The issue was identified while conducting the Unit 1 biennial LORT Program inspection
during the week of October 16, 2006. Constellation allowed operating crews to validate
simulator exam scenarios that were substantially the same as the simulator exam
scenarios that were later administered to these crews as part of their annual operating
test, thus preconditioning the operators (see preliminary white finding discussed in item
b.1 above for details). These practices did not comply with Constellations procedural
guidance, in NMP-TR-1.01-20, Attachment 5, Section B.2 which states, Personnel shall
not validate any materials to be used on their exams, and Section D which stipulates
Enclosure
8
each section of the requalification exams will contain at least 50% new material.
The NRC inspection team communicated these issues to Constellation representatives.
On October 20, 2006, representatives of Constellation management agreed with the
NRC inspection teams assessment of the issues. The licensee then conducted an
extent of condition review for Unit 2 annual license operating tests administered to date
and determined the exams administered to date were invalid due to the pervasive nature
of the apparent exam compromise. Exam administration was suspended at both units
pending development of new exams. The licensee initiated Condition Report CR-NM-
2006-4808, dated October 19, 2006 that documented this issue and later initiated a
Category I Root Cause Analysis (CR-NM-2006-4808), Annual Licensed Operator
Requalification Exam Compromise.
Following the onsite visit, the NRC inspection team conducted an in-office extent of
condition review of the Unit 2 2005 dynamic operating tests. The team determined that
the 2005 Unit 2 dynamic exams were not affected.
The licensees root cause team later concluded, ...that similarities in the scenarios in
the 2006 Unit 1 exam set caused unintentional preconditioning of the crew by exposing
them to scenarios during validation that were essentially the same as the scenarios
used for their exam ... and reviewed the 2006 Unit 2 and 2005 Unit 1 exam sets and
found issues similar to those associated with the 2006 Unit 1 exam.
New and more comprehensive scenario exam scenarios were developed and
administered to all licensed operators between November 20 and December 14, 2006.
The inspection team observed the re-testing of all Unit 1 and some of the Unit 2 licensed
operators.
Analysis. The unintentional integrity compromise of the simulator exam scenario portion
of the 2006 Unit 2 annual operator exams was a performance deficiency, in that
Constellation failed to follow their established requalification procedures and violated
10 CFR 55.49. Integrity of Exams and Tests. Specifically, initially in 2006 the
operators were tested using simulator exam scenarios substantially similar to simulator
exam scenarios that they had previously validated. Therefore, the validation process, in
combination with a lack of exam diversity, caused exam integrity to be compromised.
Traditional enforcement does not apply because the issue did not have any actual safety
consequences or potential for impacting the NRCs regulatory function and was not the
result of any willful violation of NRC requirements or Constellations procedures. This
finding was more than minor because it was associated with the Human Performance
attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones
and affected the combined objective of: limiting the likelihood of; ensuring the availability
and reliability of mitigating systems to respond to; and providing reasonable assurance
that physical barriers protect the public from radio nuclide releases caused by, initiating
events.
This finding was determined to have very low safety significance (Green) using
Appendix I of the SDP. Block 21 applies, Has the integrity of the scenario been
Enclosure
9
compromised? This is a failure to control the scenario identity or material including
the validation process such that the operating test integrity is affected. The answer
to the Block 21 question is yes, the operators were tested using requalification exam
scenarios substantially similar to exam scenarios that they had previously validated.
Therefore, the validation process in combination with a lack of scenario diversity, led to
an exam compromise. Block 26 also applies, When the compromise was discovered,
or should have been discovered, did the licensee take immediate compensatory
measures also applies. The answer to the Block 26 question is yes resulting in a
green finding (Block 21 - Yes and Block 26 - Yes), This simulator exam scenario
integrity compromise finding should have been discovered and corrected prior to NRC
identification. However, following identification Constellation took immediate and
substantive compensatory actions to remedy the 2006 annual operating exam
compromise, by developing new exams and re-testing all the Unit 2 licensed operators
within the required annual and biennial exam cycles. Further, the inspectors verified
that the Unit 2 2005 simulator exam scenario portion of the annual operating exam had
not been compromised in a similar fashion.
The cause of the finding has a cross-cutting aspect in the area of problem identification
and resolution in that Constellation did not effectively collect, evaluate, and
communicate applicable external operating experience to affected internal stakeholders
nor did they conduct self-assessments of sufficient depth that were comprehensive,
appropriately objective and self-critical such that the 2006 Unit 2 exam compromise
issues were either avoided altogether or at least identified and corrected by
Constellation prior to the start of this inspection.
Enforcement. 10 CFR 55.49, requires, in part, that, ...licensees shall not engage in any
activity that compromises the integrity of any application, test, or examination required
by this part. The integrity of a test or examination is considered compromised if any
activity, regardless of intent, affected, or, but for detection, would have affected the
equitable and consistent administration of the test or exam. Contrary to this
requirement, the 2006 Unit 2 annual operating tests were compromised since the
process used to validate the simulator exam scenarios resulted in licensed operators
being knowledgeable of a significant portion of the test prior to its administration.
(NCV 05000410/2006011-02, Failure to Ensure Integrity of Unit 2 Examinations and
Tests)
3. Unit 1 Crew Failure Rate on the Dynamic Simulator Portion of the Annual Operating
Examinations
Introduction. A finding of very low safety significance (Green) was identified at Unit 1,
based on two of six crews failing their facility-administered annual simulator
examinations.
Description. During facility-administered annual operating testing of the licensed
operators, licensee training staff evaluated crew performance on simulator exam
scenarios using performance standards derived from NUREG-1021, Operator
Enclosure
10
Licensing Examination Standards for Power Reactors. Facility results of crew
performance showed that two of the six crews evaluated (33%) did not pass their
simulator exams. The failures are documented in licensee-initiated Condition Report
CR 2006-5797, which resulted in Constellation conducting a Category I Root Cause
Analysis. Constellations root cause analysis report stated, The number of individual
and crew failures could be indicative of programmatic weaknesses that if unresolved,
could affect operator performance on shift, ... 9 of 14 individuals failing the annual
operating exam had been noted as needing improvement in the same areas as on the
annual exam (within the last 2 years). 3 of 4 crews failing the annual exam failed a
recent evaluated scenario (in 2006) and all 4 crews had failed a scenario in the last 2
years. Ops Management was not fully aware of these performance weaknesses. Other
than documentation of remediation for failures, no other documentation was found as
described performance improvement plans for individuals noted as needing
improvement as required by GAI-OPS-13. GAI-OPS-13, Attachment 1.2, states that,
...a score of one or two in any competency area or on any event or evolution requires
development of a plan for improving performance. NRC inspectors observed the
administration of the simulator exam scenario evaluations for all six crews and also
observed the retest of one of the remediated crews that failed their exam during a
previous week.
Analysis. A performance deficiency (PD) was identified in that the Systems Approach to
Training (SAT) feedback mechanism standards associated with the Nine Mile Point
LORT program were not utilized. Specifically, individual and crew weaknesses were not
appropriately identified, evaluated and corrective actions taken. In addition, corrective
actions taken for previously identified individual and crew weaknesses were not fully
effective (i.e., a Category 1 CR written in 2004 to document a green finding from crew
failures on an annual exam). As a result, two of six licensed operator crews
demonstrated knowledge and ability weaknesses resulting in less than adequate
performance on an NRC required requalification test administered by the licensee.
Traditional enforcement does not apply because the issue did not have any actual safety
consequence or potential for affecting the NRCs regulatory function and was not the
result of any willful violation of NRC requirements or licensee procedures. This finding
was more than minor because it was associated with the Human Performance attribute
of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and
affected the combined objective of: limiting the likelihood of; ensuring the availability and
reliability of mitigating systems to respond to; and providing reasonable assurance that
physical barriers protect the public from radio nuclide releases caused by, initiating
events. Specifically, the finding reflected the potential inability of the crews to take
appropriate safety-related actions in response to actual abnormal or emergency
conditions while they were on-shift prior to the requalification testing.
Since this is a more than minor requalification training issue, the risk importance
associated with the number of crews failing the annual operating tests is provided in
Appendix I of the SDP. The Simulator Operational Evaluation Matrix was entered using
the number of crews that took the simulator test, six, and the number of crews with less
than adequate performance, two. Based on these numbers, the finding was
characterized by the SDP as having very low safety significance (20 - 34% failure rate),
Enclosure
11
or Green. The finding is of very low safety significance because the failures occurred
during annual testing of the operators on the simulator, because there were no actual
consequences to the failures, because the crews were removed from watch standing
duties, retrained, and re-evaluated before they were authorized to return to control room
watches, and because the crew failure rate for the 2005 Unit 1 Annual Operating Exams
was less than 20%.
Enforcement. NRC regulations require that licensed operators pass an annual
operating test; the regulations do not specify pass/fail rates. When a failure occurs,
requirements are met by restricting the operator from licensed duties until the operator
has been retrained and successfully retested, steps which licensee staff completed.
Therefore, no violation of regulatory requirements occurred. Crew performance on the
2006 annual operating exams has been entered into the corrective action program
(CAP) as CR 2006-5797, and Constellation performed a level 1 root cause analysis of
these crew failures. (FIN 05000220/2006011-03, Unit 1 Crew Failure Rate on the
Dynamic Simulator Portion of the Annual Operating Examinations)
4. Unit 2 Crew Failure Rate on the Dynamic Simulator Portion of the Annual Operating
Examinations
Introduction. A finding of very low safety significance (Green) was identified at Unit 2,
based on two of six crews failing their facility-administered annual simulator
examinations.
Description. During facility-administered annual operating testing of the licensed
operators, licensee training staff evaluated crew performance on simulator exam
scenarios using performance standards derived from NUREG-1021, Operator
Licensing Examination Standards for Power Reactors. Facility results of crew
performance showed that two of the six crews evaluated (33%) did not pass their
simulator exams. The failures are documented in licensee-initiated Condition Report
CR 2006-5797, which resulted in Constellation conducting a Category I Root Cause
Analysis. Constellations root cause analysis report stated, The number of individual
and crew failures could be indicative of a programmatic weaknesses that if unresolved,
could affect operator performance on shift, ... 9 of 14 individuals failing the annual
operating exam had been noted as needing improvement in the same areas as on the
annual exam (within the last 2 years). 3 of 4 crews failing the annual exam failed a
recent evaluated scenario (in 2006) and all 4 crews had failed a scenario in the last 2
years. Ops Management was not fully aware of these performance weaknesses. Other
than documentation of remediation for failures, no other documentation was found as
described performance improvement plans for individuals noted as needing
improvement as required by GAI-OPS-13. GAI-OPS-13, Attachment 1.2, states that,
...a score of one or two in any competency area or on any event or evolution requires
development of a plan for improving performance. NRC inspectors observed the
administration of the simulator exam scenario evaluations for two of six crews and also
observed the retest of one of the remediated crews that failed their exam during a
previous week.
Enclosure
12
Analysis. A performance deficiency (PD) was identified in that the Systems Approach to
Training (SAT) feedback mechanism standards associated with the Nine Mile Point
LORT program were not utilized. Specifically, individual and crew weaknesses were not
appropriately identified, evaluated and corrective actions taken. In addition, corrective
actions taken for previously identified individual and crew weaknesses were not fully
effective (i.e., a Category 1 CR written in 2004 to document a green finding from crew
failures on an annual exam). As a result, two of six licensed operator crews
demonstrated knowledge and ability weaknesses resulting in less than adequate
performance on an NRC required requalification test administered by the licensee.
Traditional enforcement does not apply because the issue did not have any actual safety
consequence or potential for affecting the NRCs regulatory function and was not the
result of any willful violation of NRC requirements or licensee procedures. This finding
was more than minor because it was associated with the Human Performance attribute
of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and
affected the combined objective of: limiting the likelihood of; ensuring the availability and
reliability of mitigating systems to respond to; and providing reasonable assurance that
physical barriers protect the public from radio nuclide releases caused by, initiating
events. Specifically, the finding reflected the potential inability of the crews to take
appropriate safety-related actions in response to actual abnormal or emergency
conditions while they were on-shift prior to the requalification testing.
Since this is a more than minor requalification training issue, the risk importance
associated with the number of crews failing the annual operating tests is provided in
Appendix I of the SDP. The Simulator Operational Evaluation Matrix was entered using
the number of crews that took the simulator test, six, and the number of crews with less
than adequate performance, two. Based on these numbers, the finding was
characterized by the SDP as having very low safety significance (20 - 34% failure rate),
or Green. The finding is of very low safety significance because the failures occurred
during annual testing of the operators on the simulator, because there were no actual
consequences to the failures, because the crews were removed from watch standing
duties, retrained, and re-evaluated before they were authorized to return to control room
watches, and because the crew failure rate for the 2005 Unit 2 Annual Operating Exams
was less than 20%.
Enforcement. NRC regulations require that licensed operators pass an annual
operating test; the regulations do not specify pass/fail rates. When a failure occurs,
requirements are met by restricting the operator from licensed duties until the operator
has been retrained and successfully retested, steps which licensee staff completed.
Therefore, no violation of regulatory requirements occurred. Crew performance on the
2006 annual operating exams has been entered into the corrective action program
(CAP) as CR 2006-5797, and Constellation performed a level 1 root cause analysis of
these crew failures. (FIN 05000410/2006011-04, Unit 2 Crew Failure Rate on the
Dynamic Simulator Portion of the Annual Operating Examinations)
4. OTHER ACTIVITIES (OA)
Enclosure
13
4OA5 Other
1. Acceptability or Suitability of Nine Mile Point Unit 1 and Unit 2 Simulator Scenario-
Based-Tests (SBTs) For Meeting ANSI/ANS-3.5-1998 Performance Testing Criteria
The inspectors reviewed actions taken by Constellation since this item was opened
during a 2004 Licensed Operator Requalification Program inspection and determined
that this item will remain open pending further NRC review (i.e., the NRC has not
reached final resolution with the industry regarding an acceptable level of test
documentation to support this approach). (URI 05000220&410/2004005-03,
Acceptability or Suitability of Nine Mile Point Unit 1 and Unit 2 Simulator Scenario-
Based-Tests (SBTs) For Meeting ANSI/ANS-3.5-1998 Performance Testing Criteria)
4OA6 Meetings, including Exit
The lead inspector and the NRC Region I Operations Branch Chief presented the
inspection results to members of licensee management team in an onsite meeting at the
conclusion of the inspection on January 18, 2007. No materials reviewed were
identified by the licensee as proprietary.
Enclosure
A-1
ATTACHMENT
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee Personnel
T. OConnor, Site Vice President/Plant General Manager
M. Schimmel, Plant General Manager
N. Conicella, Operations Manager
T. Shortell, Training Manager
M. Miller, Director Licensing
B. Brown, General Superintendent Operations Training
J. Krakuzeski, Unit 1 Operations Supervisor
R. Slade, Unit 2 Operations Supervisor
D. Newman, Supervisor Operations Requal
M. McCrobie, Simulator Support Supervisor
M. Peterson, U1 Simulator Test Specialist
E. Benedicto, U1 Simulator Software Engineer
D. Kelly, Requal Exam Developer
G. Bobka, Operations Training
W. Coppom, Operations Training
NRC Personnel
L. Cline, Senior Resident Inspector
E. Knutson, Resident Inspector
J. Caruso, Senior Operations Examiner/Inspector
P. Presby, Operations Examiner/Inspector
R. McKinley, Operations Examiner/Inspector (UI)
J. Sullivan, Operations Examiner/Inspector (UI)
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
05000220/2006011-01 AV Failure to Ensure Integrity of Unit 1 Examinations and
Tests (Section 1R11.1)05000410/2006011-02 NCV Failure to Ensure Integrity of Unit 2 Examinations and
Tests (Section 1R11.2)05000220/2006011-03 FIN Unit 1 Crew Failure Rate on the Dynamic Simulator Portion
of the Annual Operating Examinations (Section 1R11.3)
Attachment
A-2
05000410/2006011-04 FIN Unit 2 Crew Failure Rate on the Dynamic Simulator Portion
of the Annual Operating Examinations (Section 1R11.4)
Discussed
05000220&410/2004005-03 URI Acceptability or Suitability of Nine Mile Point Unit 1 and
Unit 2 Simulator Scenario-Based-Tests (SBTs) For
Meeting ANSI/ANS-3.5-1998 Performance Testing Criteria
LIST OF DOCUMENTS REVIEWED
Procedures:
TAP-TQS-04 NMP Examination Standard Rev. 07
NTP-TQS-102 Licensed Operator Requalification Training Rev. 35
NTP-TQS-400 Instructions for Completing and Processing NRC Forms 396 and 398 Rev. 18
S-FFD-16 Fitness for Duty Procedure Rev. 04
S-ODP-TQS-0101 Administrative Controls for Maintaining Active License Status at NMP Rev.
04
GAI-OPS-13 Operations Score Card Program Rev. 03
NMP-TR-1.01-10 Analysis Phase Activities Rev. 0
NMP-TR-1.01-20 Design Phase Activities Rev. 0
NMP-TR-1.01-30 Development Phase Activities Rev. 0
NMP-TR-1.01-40 Implementation Phase Activities Rev. 0
NMP-TR-1.01-50 Evaluation Phase Activities Rev. 0
NMP-TR-1.01-60 Simulator Operation & Testing Rev. 0
NMP-TR-1.01-70 Training Administration Rev. 0
Other:
CR-NM-2006-4808
Category I Root Cause Analysis (CR-NM-2006-4808), Annual Licensed Operator
Requalification Exam Compromise
NMP1 2006 Biennial Exam Sample Plan
NMP1 Biennial Schedule 05/06 Rev.1
NMP1 Independent Self-Assessment Report, Assessment #: FSA-2006-43
Scenarios:
- O1-OPS-009-1-DY-71 rev. 0 AWTS w/ Main Condenser
- O1-OPS-009-1-DY-63 rev. 0 AWTS w/ Main Condenser
- O1-OPS-009-1-DY-05 rev. 4 AWTS w/o Main Condenser
- O1-OPS-009-1-DY-11 rev. 4 AWTS w/o Main Condenser
- O1-OPS-009-1-DY-17 rev. 2 AWTS w/o Main Condenser
- O1-OPS-009-1-DY-18 rev. 8 AWTS w/ Main Condenser
- O1-OPS-009-1-DY-25 rev. 6 Steam Leak in Drywell w/ blowdown
- O1-OPS-009-1-DY-39 rev. 6 Steam Leak in Drywell
Attachment
A-3
- O1-OPS-009-1-DY-48 rev. 4 AWTS w/ Main Condenser
- O1-OPS-009-1-DY-50 rev. 2 AWTS w/ Main Condenser and Torus Leak
- O1-OPS-009-1-DY-53 rev. 3 Steam Leak in Drywell
- O1-OPS-009-1-DY-54 rev. 3 AWTS w/o Main Condenser
- O1-OPS-009-1-DY-55 rev. 1 AWTS w/ Main Condenser
Open Simulator Deficiency Reports (DRs)
Scheduled Simulator Enhancements
Simulator Training Load Acceptance Reports
- June to August 2006
- Dec. 2005 to March 2006
- Sept. to Dec. 2005
- July to Sept. 2005
Simulator Exceptions List
Simulator Four Year Test Schedule
Simulator Configuration Control Board (SCCB) Meeting Minutes:
- October 19, 2005
- August 4, 2006
- July 14, 2006
Simulator Documents related to Jan 2004 Emer Cooling Test (NCV05000220/2004005-02)
- DR 3531
- DR 3538
- Upgrade DR 80
2005 Simulator Model Test, ANSI 3.5 Appendix "B" B1.2(3) Simultaneous Closure of All MSIVs
Simulator Deficiency Reports
- DR 3884, Recirc Pump Metering
- DR 3799, Offgas Controller
- DR 3798, RWCU Conductivity
- DR 3797, Indicator Should Read Downscale
- DR 3789, Safety Valve Outlet High Temperature
- DR 3782, Pressure Oscillation with TC05 Initiated
- DR 3760, Malfunctions FW29A&B Do Not Work
- Upgrade DR 165, Change Sim Status Hi Press Setting
Condition Reports Related to Simulator
- CR-NM-2005-542, NRC Identified Green NCV
- CR-NM-2005-615, NRC Identified URI on Suitability of SBTs
Simulator Scenario Based Tests for Cycle C09 and Cycle 10 (2006)
Simulator vs. Plant Comparison for Stuck Open ERV
Simulator vs. Plant Comparison for 8/3/04 Feedwater Spiking, Manual Scram
2005 Simulator Steady State Comparisons at 40%, 75% and 100%
Attachment