NUREG-1201, Transcript of 860606 Commission Briefing in Washington,Dc by Davis-Besse Ad Hoc Review Group.Pp 1-65.NUREG-1201, Rept of Independent Ad Hoc Group for Davis-Besse Incident, Encl: Difference between revisions

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{{Adams
#REDIRECT [[NUREG-1201, Forwards Proposed Commission Policy Statement on Integrated Scheduling of Plant Mods,Proposed Commission Paper & Supporting Info,For CRGR Consideration]]
| number = ML20211E223
| issue date = 06/06/1986
| title = Transcript of 860606 Commission Briefing in Washington,Dc by Davis-Besse Ad Hoc Review Group.Pp 1-65.NUREG-1201, Rept of Independent Ad Hoc Group for Davis-Besse Incident, Encl
| author name =
| author affiliation = NRC COMMISSION (OCM)
| addressee name =
| addressee affiliation =
| docket = 05000346
| license number =
| contact person =
| case reference number = REF-10CFR9.7, RTR-NUREG-1201
| document report number = NUDOCS 8606130288
| document type = LEGAL TRANSCRIPTS & ORDERS & PLEADINGS, TRANSCRIPTS, DEPOSITIONS, NARRATIVE TESTIMONY
| page count = 145
}}
 
=Text=
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e                a ORIGINAL                    .
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UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION In the matter of:
COMMISSION MEETING Briefing by Davis-Besse Ad Hoc Review Group (Public Meeting)
___ _ _ _ _ ..__ _ ____ _____. ___ _ 2 7 Docket No.
1.
\                            .
Location: Washington, D. C.                                            1 - 65 l                                                      Date: Friday, June 6, 1986                              Pages:
t                                                                          ANN RILEY & ASSOCIATES
(                                                                          Court Reporters s--                                                                      1625 I St., N.W.
Suite 921 Washington, D.C. 20006 8606130288 860606                                                  (202) 293-3950 PDR                10CFR PT9.7                            PDR
* n 1
D I SCLA I MER 2
l U                                                                                            !
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l 4                                                                                            ,
5 6                  This is an unofficial transcript of a meeting of the 7      United States Nuclear Regulatory Commission held on 9      6/06/86        .
In the Commission's office at 1717 H Street, 9      N.W.,  Washington,  D.C.            The meeting was open to public 10      attendance and observation.                        This transcript has not been 11      reviewed, corrected, or edited, and it may contain 12      inaccuracies.
13                  The transcript is intended solely for general 14      informational purposes.              As provided by 10 CFR 9.103,          it is 15    not part of the formal or informal record of decision of the l
16    matters discussed.            Expressions of opinion in this transcript i
17    do not necessarily reflect final determination or beliefs.                          No 18    pleading or other paper may be flied with the Commission in 19    any proceeding as the result of or addressed to any statement 20      or argument contained herein, except as the Commission may 21      authorize.
22 23 24 25
 
e  o 1
1                      UNITED STATES OF AMERICA 2                  NUCLEAR REGULATORY COMMISSION 3                                    ---
4          BRIEFING BY DAVIS-BESSE AD HOC REVIEW GROUP 5                                ---
6                            PUBLIC MEETING 7                                ---
8                                      Nuclear Regulatory Commission 9                                      Room 1130 10                                      1717 "H" Street, N.W.
11                                      Washington,  D.C.
12 13                                      Friday, June 6, 1986 s
14 15              The Commission met in open session, pursuant to 16  notice, at 2:A5 o' clock p.m. , NUNZIO J. PALLADINO, Chairman of 17  the Commission, presiding.
18  COMMISSIONERS PRESENT:
19              NUNZIO J. PALLADINO, Chairman of the Commission 20              THOMAS M. ROBERTS, Member of the Commission 21              JAMES K. ASSELSTINE, Member of the Commission 22              FREDERICK M. BERNTHAL, Member of the Commission 23              LANDO W. ZECH, JR., Member of the Commission 24 25
 
e  p 2
1                      STAFF AND PRESENTERS SEATED AT COMMISSION TABLE:
.        2                                            M. MALSCH 3                                            B. CLEMENTS 4                                            J. GLEASON 5                                            P. MORRIS 6                                            D. RATHBUN 7                                            J. LEVINE 8                                            H. TINSLEY 9
10 11 12 13 14 15 16 17                                                                                  ;
18 19
,  20 l
21 22 i
23 24 25 i
 
        #      D 3
1                                      P R O C E.E;D I N G S 2                    CHAIRMAN PALLADINO:          Good afternoon, ladies and 3    gentlemen.,        This afternoon the Davis-Besse Ad Hoc Review 4    Group will brief the Commission on its report on the June 9, 5    1985 Davis-Besse Nuclear Power Plant Loss of Feedwater Event.
6                    Prior to the formation of the Ad Hoc Review Group, 7    the Executive Director of Operations dispatched an Incident 8    Investigation Team known as an IIT to determine the facts 9    surrounding the June 9, 1985 event to identify the probably 10      causes of the event and to form conclusions and make 4            11      recommendations as to the basis for corrective action.                                                                  The i
  !          12      results of this investigation was documented in NUREG-1154.
f      13                      In January of this year, the Commission established 14      the independent Ad Hoc Review Group to review issues 15      subsequent to the loss of the feedwater event at Davis-Besse 16        as well as the Davis-Besse IIT's investigation.                                                                This group 17      was to identify any, additional lessons that might be learned 18 from the incident and from those to make recommendations about 19      how NRC internal procedures and oversight of reactor licensees 20        might be improved.
21                        By memo dated May 2, 1986 the Chairman of the Review 22        Group forwarded the group's report and I understand that
,          23        copies of the report are available on the table in the back of i
24        the room.
25                        Following the briefing by the Ad Hoc Group, I
 
e  .
4 1  believe that the Commission ought to consider the type of 2  follow-up action that it wants to see taken as a result of the 3 Ad Hoc Group report.      For example, the Commission might want 4  to task the staff to prepare an action paper for Commission 5  review based on this report.
6            I look forward to hearing today's presentation with 7 great interest.      I would like to thank the members of the Ad 8 Hoc Review Group for their efforts.                    In particular, I want to 9 thank Mr. Levine of NASA and Mr. Tinsley of FAA for their 10  valuable participation.
11            Let me ask now if any of my fellow Commissioners 12  have opening remarks they would like to make?
(  13            (No response..)
14            CHAIRMAN PALLADINO:      If not, then let me turn the 15  meeting over to Mr. James Gleason, Chairman of the Davis-Besse 16  Ad Hoc Review Group.
17            (SLIDE.)    ,
18            MR. GLEASON:    Thank you, Mr. Chairman and members of 19  the Commission and I am speaking for all of the members of the 20  Ad Hoc Group. I think we have all appreciated the opportunity 21  to participate in this review and to try to help you identify 22  any additional lessons which can be learned from the loss of 23  feedwater incident of 1985.
24            As you know, at the beginning you designed to 25  appoint a multi-agency group and have a group which had
 
l 5
l 1 different disciplines and perspectives with it.
2            (SLIDE.)
3          MR. GLEASON:    Mr. Tinsley from the FAA has a safety 4 and human factors background. Mr. Levine has a reliability 5 and quality assurance background and is with the Johnson 6 Space Center in Houston. Dennis Rathbun, I am sure all of you 7 know, is the deputy director of OPE.      Dr. Morris and myself 8 are from the Licensing Board and Pete, of course, is a former 9 director of licensing at the AEC.
10            I think it goes without saying, it was a 90-day 11  effort and it was a full-time activity.      We had to compile an 12  extensive library of documents, reports and correspondence
{  13  dealing with the Agency and dealing with the utility which 14  goes back a period of eight or nine years.
15            We should say and I should say that we had excellent 16  cooperation not only from the staff but also from the utility 17  as well. We conducted.about 50 interviews during the time 18  period. We visited with all of the top staff directors of the 19  Agency.
20            We visited with the top personnel of Davis-Besse and 21  the regional administrator of Region III.      We visited with the 22  members of INPO, the Chairman of the ACRS, the top officers at 23  Babcock and Wilcox and we also visited not only with the IIT 24  group on Davis-Besse but the Chairman of the other two 25  incident groups, San Onofre and Rancho Seco because of their i
l
 
6 1  sgquence, trying to find out what additional procedures could 2  have benefited from that experience.
3          We also thought it wise and well to bring in the 4  executives from four utilities to get some benchmark kind of 5  comments and they were from Commonwealth Edison, Florida 6  Power Corporation, the Duke Power Company and SMUD, Sacramento 7 Municipal Utility District, and we will be talking about that 8  a little bit later.
9          We visited the Davis-Bosse plant for several days.
10  We visited the INPO organization in Atlanta as I indicated and 11  we also looked in at the training simulator at Babcock and 12  Wilcox in Lynchburg.
13            Essentially what we prepared to brief you with are 14  keys to the conclusions and recommendations of the four tasks 15  that we were given.
16            (SLIDE.)
17            MR. GLEASON:    The Charter, as you can see, had us 18  looking at the process which was in existence concerning the 19  AFWS. It had us look at the pre-event probabilistic 20  assessments of the system. It told us to take a look at the 21  licensee's management operation and maintenance programs as it 22  contributed or as they may have contributed to equipment 23  failures which related to the incident and finally, we were 24  told to look at the IIT Davis-Besse activity.
25            We were restricted to refresh your memory in two
 
    . o 7
1 1 areas, we were not to have any responsibility for determining 2 whether the facility could be operated without undue risk to 3 public health and safety and we were not to assess or attempt 4 to assass any responsibility for the incident itself and I 5 think we religiously stayed away from both of those areas.
6            (SLIDE.)
7          MR. GLEASON:  We look at the first task by reviewing 8 the regulatory process concerning the auxiliary feedwater 9 system. We traced a rather lengthy paper trail of significant 10  events which related to the system. I think in the report 11  there documents some 34 to 35 events. I would just like to 12  talk about four or five or six of these, the significent ones
  /  13  which I am sure that you probably have had some reading on in 14  the past but just to refresh your memory as it relates to the 15  work that we did.
16            You may recall that after TM1 in the SER that 17  accompanied the start-up of Davis-3stise, they were shut down 18  after TMI as other Babcock and File < facilities were, the 19  staff required a greater degree of diversity in the AFWS 20  system in order t,o provide an additional motor operated pump 21  or an alternative acceptable to the staff..
22            Shortly thereafter in May of 1980 as a result of an 23  event at Crystal River the staff did an additiondI study 24  dealing with just B&W reactors looking at the transient 25  responses and that report recommended a diverse drive pump for 4
              -n-,              .          --
 
8          )
I 1 Davis-Besse and I also would note at this time, they did not 2 call at that time for an alternative. At least those words 3 were not included in the report.
4            In June of 1981 jumping a year ahead, the standard 5 review plan amendments came up with a reliability criterion 6 for AFWS systems for failure of the system on demand which is 7 adopted in the plan of a criterion of ten to the minus four to 8 ten to the minus fifth. That plan did not apply to existing 9 operators, of course, -- existing facilities of which 10  Davis-Besse was one.
11            Although throughout that period the various members 12  of the staff continued to call for the facility to come
(~  13  forward with this new requirement for an additional motor 14  operated pump, Davis-Besse concluded that it was too expensive 15  and they decided to do an analysis of their own which would 16  tend to look at an alternative.
17            They performed this and it was delivered to the 18  staff in December of 1981. That PRA was sent to BNL which was 19  looking at all of the PRAs done on Babcock and Wilcox 20  utilities but they performed and BNL instead of reviewing that 21  study decided to do a PRA of its own and it performed its work 22  and did the work in conformity using the data and the criteria 23  in the standard review plan.
24            The difference now between those two was somewhat 25  significant. In the Davis-Besse, they were allowing some
 
9    ,
l 1  credit for a feed and bleed mode of operating and in the BNL    l 2  and they were using a different success criterion, this feed 3  and bleed within a 30-minute period and their success 4 criterion was related to recovery of the core -- keeping the 5 core cool and the BNL study was directed at whether the 6 hardware would function accurately on demand.
7            BNL performed their PRA and they came up with their 8 report in February of 1983. So, in effect, what you had were 9 two PRAs, both dissimilar and both using different 10  assumptions.
11              During this period of time the various members of 12  the staff were also considering and did consider whether the f~  13  problem at Davis-Besse ought to be included in a generic 14  approach and also whether it ought to be included as part of 15  the A-45 unresolved safety issue, the resolution of decay heat 16  removal problem.
17              Finally, in 1984, Davis-Besse during an outage in 18  which they had to use their own startup pump to test certain 19  things with respect to a new core brought forth that they had 20  an unanalyzed problem in the plant which related to avoidance 21  of high or moderate energy pipe break.
22              They wanted to use the startup pump to get their 23  facility started again and the staff at that time decided they 24  would do a little swapping and the swap was they could do it 25  if they would put in a new startup pump.
* O 10 1                      So that was the real resolution of the third train 2          if you will and they were presumably supposed to do that, 3          there was a license amendment and they were called to do that 4          at the next outage which was scheduled for 1986.                      Of course, 5          in the interim period, the June 9 event occurred.                      That new 6          startup pump is now in existence.
7                      Throughout this period all the way from TMI all 8            through 1985, there were a number of problems connected with 9            the system, recurring problems.                      They involved components, 10            design changes. There were license amendments but they were 11            taken care of but no resolution of the problem was ever 12            arrived at until this fix that I have just referred to
    /      13            occurred in the latter part of 1983 and 1984.
14                      There was in our opinion a technical justification 15            that a diverse pump power could have been required because of 16            its prior bad experience and it was a year long dispute, of 17            course, that occurred over whether the AFWS at Davis-Besse 18            ought to be included in a generic package or ought to be 19            included within the A-45 decay heat removal program.
20                      The ACRS throughout this period has looked in some 21            general aspects.      They actually have a subcommittee on the 22            AFWS system but their approach has been geared more towards a 23            generic solution.      They never looked specifically at the 24            Davis-Besse facility itself.
25                        (SLIDE.)
.\
 
11 1              MR. GLEASON:  Our recommendations that flow out of 2  this review or the background are essentially this.              Well, I 3  have already done over the conclusions.            I have gone over the 4  conclusions in essence in my recital there.
5              We believe there was some vital information slipping 6  through the cracks in the Agency.        There was a lot of which I 7  will get into later when we get to the looking at the third 8  assignment, there was a lot of activity, oversight activity, 9  from Region III and there was obviously a lot of activity 10    going on as to whether the third pump would be required and 11    the probability assessments that were being made by NRR 12  ' dealing with the AFWS.        But apparently the twain never met.
13                COMMISSIONER ASSELSTINE:
(                                                      Why?
14                MR. GLEASON:  My theory is that there was such and 15    we get into this a little bit later, there was such an 16    involved -- speaking now from the Region III aspect, I can't 17    really give a complete answer from the NRR aspect, that there 18  was such activity going on, there was such regulatory 19  oversight gcing on that just nobody ever sat back and said, 20    "What does it all mean?"
21                They were so intense in their activity and getting 22  on with things and getting changes made, now that is one part 23  of it, that is the Region III part.
24                We do have a project manager.      He is responsible, of 25  course, for everything that flows through NRR and I&E dealing
 
12 1 with that plant. I am not sure how much he was involved with 2 the SALP process. He is supposed to be. He indicated that he 3 had not visited the plant as much as he would have liked.        If 4 he had, he would have certainly seen a lot of things that were 5 happening in the oversight process.
6          So things were falling through a crack and out of 7 that, of course, has come the recommendation which we think is 8 a very good one and which we endorse here that they ought to 9 take a quarterly look at the bad plants and bring into one 10  room the top officials at the Agency as well as the 11  administrators of the Region and take a look at those plants 12  that have deteriorating problems and make decisions right then
(  13  and there and that is what occurred, of course, in their first-14  meeting that was held April 23rd and 22nd.
15            COMMISSIONER ASSELSTINE:    I certainly understand the 16  recommendation and I agree with it. I guess what I am looking 17  for a bit more is the sense I got from the report was that 18  there were people, indeed perhaps many people, in NRR that 19  were quite concerned about the reliability of this system and 20  were quite insistent about the need to improve reliability of 21  the auxiliary feedwater system, were very concerned about its 22  potential for contribution to a serious accident and the i    23  marginsi nature of the system.
24            At the same time, there were people in the region 25  who were quite concerned about the historically poor level of
 
13 1 operating performance of this particular plant.
2          The sense I get from your report is that the two 3 were not talking to each other.            I guess what I am wondering 4  is, what is it about this organization that led to that kind 5 of a breakdown?    Why is it, if I am right that the two sides 6 of the house weren't taking to each other, what led to that 7 with fairly significant consequences in this case?
8          MR. GLEASON:    Well, I have given you at least one 9 answer as to my own conclusion as to what led to it and as far 10  as Region III is concerned.            I just think they are so heavily 11  involved with changes that were being made, there was a very 12  significant oversight activity going on.
13            But Mr. Keppler himself has said, he said to us, I
(
14  presume he has said it to you people, that he never realized 15  that these things were not coordinated, were not meeting.
16  Mr. Denton and Mr. Keppler have both said that if they knew 17  what was going on as they knew after the event, they would 18  have taken some decisive action so there isn't any question 19  there was something clipping through the cracks.
20            COMMISSIONER ASSELSTINE:          Joe or Guice, you two are
,    21  more cutsiders than the rest of us and I don't know if you l
22  have any perspective on this or not?
23            MR. LEVINE:  Well, in my looking at it, I believe my 24  feeling was that the mind set at the time within NRR was very 25  much looking at the auxiliary feedwater system from a somewhat
 
4  0 14 1 isolated viewpoint.
2          I think the fact that the utility responded with a                      ;
3 more system type analysis didn't fit the pattern and as a 4 consequence, they had probler.s with it not fitting the pattern 5 while at the actual utility there was in my opinion 6 significant problems happening in terms of maintenance and 7 quality assurance that to me was more important than really 8 the other thing of the analysis itself.
9          So really I think in terms of some of the 10 recommendations and some of the things the EDO is doing right 11 now in terms of better lines of communications, I think that 12 they understand it and I think they are moving towards that r  13 direction of making sure that the left hand and right hand 14 knows what is going on.
15          CHAIRMAN PALLADINO:                      I think we need a better way 16 also of keeping before the top management of the Agency 17 important things that staff has requested be done so that they 18 are not lost sight of as time goes on and questions about them 19 can be raised.
20          MR. GLEASON:  I think that third recommendation up 21 there, Mr. Chairman, is directed specifically at that point.
22          CHAIRMAN PALLADINO:                      If the tracking system worked, 23 I guess if it works, then I guess it will accomplish what I 24 want.
25          MR. GLEASON:  It certainly will bring in one place
 
15 1      all of the data which has been spread throughout the divisions 2      heretofore.          It will give the management of the Agency a tool 3      which they have not had.
4                CHAIRMAN PALLADINO:          What I worry about -- tracking 5      systems are great but when you have hundreds of items, you 6      don't have -- you may not be bringing to the fore the crucial 7      ones such as the need for a diverse pump.            I don't mean to 8      speak against tracking systems.            They are absolutely essential 9      and they have to be used but out of the tracking system, there 10        also ought to be identification of very severe or very 11        important items that are being handled.
12                  COMMISSIONER ASSELSTINE:          Let me take your quarterly 13        meeting recommendation one step farther and see what you think 14        about it.          I like that idea, having the Regional 15        Administrators, EDO and I would say perhaps start with the 16        director of nuclear reactor regulation, the director of 17        inspection and enforcement and the regional administrator
,                    18        meeting on a fairly short periodic basis and say, looking at 19        the worst 20 plants in the country, those that really are of 20        concern to us.
i 21                  What would you think about insisting that when they 22        do that that they take a hard look at what I think is perhaps 23        a fundamental question about Davis-Besse and that is, should 24        that plant have been running on June 9th and have those three 25        people, three of the most senior people that we really rely
 
16 1  upon for their expert technical judgment say whether they are 2  comfortable with this plant running and if they are, why or if 3  the opposite is true, why and then forward that to the 4  executive director for operations, allow him to make his 5  comments and get it up to the Commission, say on a quarterly 6  basis so we have a continuing judgment as to whether we are 7  really on top of the situation for these problem plants and we 8  really understand that there is an adequate basis for the 4
9  operation of those plants.
10              COMMISSIONER ZECH:                  I think it is important to 11    realize that I think our regional administrators and other 12    responsible NRC people are doing this on a daily basis and I 13    am confident that if the regional administrator or any of our 14    responsible agency officials really felt that the plant was 15    not safe that they would make that recommendation and we could 16    act upon that.
17              So what we,need in my judgment is not only a 18    tracking system but a system of highlighting the important 19    indicators that will assist us in making this decision.                                I am 20    confident that our senior officials are making that decision 21    on a daily basis and certainly if they knew ahead of time that 22    something was going to happen, they would make such a 23    recommendation and take appropriate action.
24              So I think we need a tracking system and I think we 25    should not infer that our agency people are not doing the best 1
 
1
      .  .                                                                                                                                        )
l l
17 1            they can and making the best judgments they can to keep our 2            systems operating safely.                      I think they are doing that on a 3            daily basis.
4                        COMMISSIONER ASSELSTINE:                            I wouldn't infer that at 5            all, Lando, that they aren't making that kind of a judgment.
6            I think they are.              It appears to me that in the case of 7            Davis-Besse what was lacking was a mechanism to gather the 8              information about how bad things really were and then to focus 9            attention on that very issue so that we could get that kind of 10              judgment in that particular case.
11                          I think, at least, some people in the Agency in 12              those positions have said, "Certainly if they knew at the time l [    13              that things were as bad as they were, as the June 9th event 14              demonstrated that they were, that they would have felt that
{        15              that plant posed an undue risk."
16                          So I think the mechanism of focusing attention on 1
l      17              that kind of a decision coupled with the decision itself, I 18              certainly would agree with you that I don't think that Harold 19              or Jim would not be making those kinds of judgments on a 20              day-to-day basis but what appears to be lacking is a mechanism 21              to surface the information, get it looked at in an integrated 22              way, that is, all of these elements together.
23                          One of the things that troubles me the most about 24              this is that you have these interrelated issues that have a 25              terribly significant bearing on safe operation of the plant 4
                              - . - .    . _ . - _ _ . .      -. , , . - , , _ . - s.,,.  . . - _ _ , _ _ . _ _ . _ _ _ - . _ - _ _ . - _ . _
 
              . o 18 1                looked at on an individual basis.                                                  Harold looks at the 2                auxiliary feed pump design question.                                                  Jim looks at what is i
3                going on on a day-to-day basis.                                                  Those things aren't getting 4                put together in a way that brings together the best talent 5                this agency has and looks on a periodic basis about knowing 6                everything we know about this plant, are we really happy with 7                what is going on there to the point where we are comfortable 4
8                in saying it can run.
9                        COMMISSIONER ZECH:                                        But this is exactly why I have
.              10                recommended we get some performance indicators as I think most 11                everyone knows.
12                          I think that will help us in making those 13                decisions. What we are trying to do is look to the future.
;              14                Hindsight is one thing but we are trying to use foresight and i
j              15                make assessments.
16                          Therefore, in my view we can't base these on 17                subjective judgments but we must base them on facts and that 18                is why we need performance indicators to assist us.                                                  We will 19                always be at the end of the line, we will be making a 20                judgment, an engineering judgment, is what it is going to be 21                about.
22                          On the other hand, you make those judgments best 23              when you have facts and when we get a series of performance 24                indicators that will include, for example, the number of 25              scrams, the number of modifications that have not been done,
 
19      l 1  the chemistry of the plant, the rad waste, radiological                                )
2    protection capacity factory, availability factor, leakage at 3    the plant perhaps and a number of those kinds of things, you 4    can make up a list of about 20 or so or more or less that will 5    give you a pretty good basis on which to make a judgment.
6                  This is what I think we are doing right now.                  We 7    are trying to put that system together and my view is when we 8    get that, it will be a great tool.
9                  On the other hand, it will always be and we still 10    rely on the engineering judgment, the best judgment of our 11    very professional people.          We can't say that we are going to 12    have a magic system that is going to tell us that two years
[    13    and one day from now we are going to have a problem.
14                    But I do think that we can do a better job in 15    gathering together the data we already have and put them in a 16    format, put them on trend charts and it will give us a tool to 17    help us perhaps make better decisions and that is what we are 18    doing in this performance indicator endeavor that is going on.
l 19                  MR. GLEASON:  I would just add one ec= ment, 20    Commissioner Asselstine.        It is not clear to me despite what 21  Mr. Keppler and Mr. Denton have said, just what precise action 22    or activity they would have shut this plant down.                        If that is 23    clear to you, I would like to know it because I asked that 24    question and I didn't get any antswers.
25                  They are dealing in a legal framework and although
 
_                    _.                                              . - - ~                  _-
20 1      if somebody has said that they could send a 50.54(f) letter if j  r 2      they had a category three on a particular thing, you still 3      have to have the right words to use and so I just think that 4      somebody has to be careful in deciding.                                              These are not easy 5      decisions.
6                      This is not an easy business for any of the people, 7      the staff and it certainly -- I might say this experience of 8      being chairman of this group has been a great education for 9      me.        It is not an easy thing to run a utility plant.                                                      So this 10        is a tough business.            It is not an easy one.                                                There are no
;      11        easy answers.
4      12                          COMMISSIONER ASSELSTINE:                  I am not suggesting that
(  13        the answers are easy or that the decisions are easy at all.
14        In fact, I would say while I am all in favor of performance 15        indicators, it is far from clear to me that we are going to I
16        get a magic set of little indicators that you can just follow 17        along a chart and say, "At this point we have a serious 18        problem and at this point we don't."
19                          COMMISSIONER ZECH:        We clearly are not but that is 20        the kind of thing you need to help you make the judgment but 21        there is nothing magic about it.                      It is going to be a judgment 22        in the final analysis but with a factual set of indicators.
23        My only premise is that it should be very helpful and perhaps, 24        maybe not for sure, but perhaps will help us foresee problems.
25                          COMMISSIONER ASSELSTINE:                But even recognizing that
 
21 1              the decisions are not easy it does seem to me absolutely clear 2              that if the technical experts in this Agency reach the 3              conclusion that the quality of management and maintenance at a 4              plant are so poor that equipment is not being maintained 5              reliably, that the plant is routinely violating the 6              assumptions on which the license for this plant was issued, 7              that there are fundamental weaknesses in which the utility 8              operates and maintains the plant and that those continue for 9              month after month, year after year, as they did in the case of 10              this particular plant.
11                              There is no doubt in my mind that the Agency has the 12              authority 'to say, "Enough is enough."
  /    13                              MR. GLEASON:            I agree with you whole heartily.
14                              COMMISSIONER ASSELSTINE:            Either you fix it in a 15              certain period of time or you stop the plant until the things 16              are finally fixed.
17                              MR. GLEASON:            I agree with you but there are a lot 18              of "if's" you have just put into that equation and if those 19              are all there, fine but the question is, when are they there.
20                              COMMISSIONER ASSELSTINE:            The record of your report 21              demonstrates that they were there.
22                              COMMISSIONER BERNTHAL:            I have sat on this 23              Commission for three years now and I think you can look back 24              in history long before I ever sat here and correct me if I am 25              wrong, I don't believe any member of this Commission has ever
 
o  .
22 1 stepped forward based on generally sloppy performance and we 2 don't have a lot more staff to assess such situations right 3 now than we ever did and said, "You know, I have had enough of 4 this place. I want that plant to be shut down."  I don't 5 believe any member of this Commission has ever done that.
6            In fact, I am inclined to remark further on your 7 comment, Mr. Levine, about the comparison between -- well, I 8 want to make a comparison between this plant and Rancho Seco.
9            If I am recollecting correctly here, the major 10  difference between this plant and Rancho Seco is that in this 11  case there was at least a kind of smoking gun outstanding 12  regulatory issue that they had not put in a piece of equipment
(  13  that we really wanted them to put in and in the case of Rancho 14  Seco, it was just sort of a general malaise if I can use that 15  term in plant operations.
16              It wasn't being well run. Our regional director 17  administrator had told us that it wasn't being well run.      It 18  was management. It was bad maintenance. But then somebody 19  has to finally step forward at this table perhaps if not at 20  the staff level and say, "We have had enough. It is time to 21  shut this thing down."
22              Probably the closest we have ever come to that in 23  this Agency was the back door shutdown of Browns Ferry and it 24  wasn't the Commission that did it. It was our staff. So I 25  just want to make clear here that those decisions are always
 
23 4
1              easy after the fact but when you are approaching them, they 2              aren't very easy and I think that is what you are telling us 3              here.
4                                                    CHAIRMAN PALLADINO:                  You don't mean to imply it is 5              wrong for the staff to do that.
6                                                    COMMISSIONER ASSELSTINE:                  That's right.
7                                                    CHAIRMAN PALLADINO:                  Both of us have the 8              responsibility to search for the thing that might lead us to i
9              that decision.
10                                                      MR. LEVINE:                I think it is going to be very 11                difficult to come up with frankly precise performance i
i                      12                indicators that will give you a "yes/no" answer.
13 l      (                                                                      COMMISSIONER ASSELSTINE:                  That's right.
14                                                      MR. LEVINE:                I think from what I have seen in my 15                experience, it becomes somewhat subjective but when you go 16                into a given plant and you find no configuration management, 17              no planned maintenance, no preventive maintenance program, no 18              root cause analysis going on and you find a history of that l
l                      19              over a period of time, well, to me, that is enough 20              indicators.                                            I mean, you don't really need any more.
,                      21                                                    COMMISSIONER ASSELSTINE:                    Yes.
22                                                    MR. LEVINE:              As a matter of fact, I think Region III
!                      23              had done a considerable amount of that.                                                  So I think really a 24              lot of this is communications and I think we show a quarterly l                      25              meeting.                                  Well, it doesn't have to be quarterly.                                        It could be i
i
'I
    .-  - ..-._ _ - c        ,, _.- - -._._~..--._.. -___ _-., ,,_ .,,,_ _ -__-.___,--_.-_ .-                                  .. . ~-____-.__,_.__,_..-- ._.            _ . . , _ - _ . _ -_
 
i l
24 1    monthly or whatever frequency it needs to be and in taking to 2    Vic Stello, I know that he thinks this way and he is 3    determined to bring together all the people to make decisions 4    and I think that is the direction we ought to be going.
5            COMMISSIONER ASSELSTINE:                                  Fred, I agree with your 6    comment also that there hasn't been much of any of that from 7    the Commission and I think the answer is, " Shame on us, too."
8    I don't raise this issue for the purpose of criticizing the 9    staff.
10              I raise it from the standpoint of how do we do l  11      business and should we be developing a mechanism that goes 12      beyond just tracking performance, that gets to the point vheire 13      we actually can identify the weak performers where we really 14      have serious reservations about the continuing level of safety 15      from the plant and deal with it effectively before we have a 16      situation that costs the utility $71.5 million dollars 17      exclusive of power replacement costs.
18              CHAIRMAN PALLADINO:            Let me suggest we go on.                      We 19      are on the first of the four headings and we are on the first l
20      point of the first heading.        I am not saying it is not 21      important but we will have a chance to address it again.
l  22              (SLIDE.)
23              MR. GLEASON:  We were asked to take a look at the 24      pre-event probabilistic assessments that were made and there 25      were essentially three of them.                        The first was a generic study
 
                                                              - -                                          . , . _ . 1 - .._i  m.
25 1      done by Babcock and Wilcox on the AFWS system for their own 2      reactors that the utilities could make any design 4
3      improvements.                  They did note that the dominant contributor for 4      Davis-Besse was the loss of both trains.                                                    That was in December 5      of 1979.
:                            6                            In 1981 as I referred before there was an assessment 7      done by Toledo Edison with a startup pump for feed and bleed 8      mode within 30 minutes.                            They looked at essentially four 9    ' configurations, the last one, the fourth one, which they 10            called an analysis based configuration appeared as a better 11          alternative to them than the third train which the staff was 12            asking for.
13                                  Then finally and once again their success criterion
(
14            was the probability of core melt, finally, the BNL study of 15            1983 which was using the methodology and criteria of the 16            standard review plan which excluded feed and bleed and their 17            success criteria was a probability of the hardware on demand.
18                                  So their review time, it is obvious, covered a
!                        19            period of over three years with these differing analysis and 20            the whole period in which the thing was first raised until it 21            was resolved with the fix in 1984 covered a period of five 22            years.
23                                  We did take advantage of contracting with the i                      24            authority that we had to contract with Sandia to take a more l                      25            closer look at these PRAs and I will ask Joe Levine to kind of
 
26 1      go through their conclusions with you at this point.
2                  (SLIDE.)
l 3                MR. LEVINE:            I think overall in looking at the
}
              ,4              analyses overall, Sandia conclusions are there and we agree 5      with them.      In general, most of the analys.es provided some 6      sound recommendations technically.                                        Some of them were 7      associated with alignment of valves and sensitivity to some of 8      the components and that kind of thing.
9                  Most of them fell short of the full potential 10          because things particularly in several cases did not include 11          things like the integrated control system and the steam 12          feedwater control system and as a matter of fact because of 1
{            13          that, it more or less was isolated again to the auxiliary
,                  14          feedwater system alone and it probably would profit by having 15          looked at some of the other initiating type systems.
!                  16                    There is also a state-of-the-art limitation 17          particularly in the, Davis-Besse event in terms of human 18          factors. You will notice in the 1154 report pushing the wrong 19          buttons, I am not sure how one really fixes that thing up but 20          that is a fact and in that respect, could not include 21          everything in that area.
22                    overall, the methodologies and the data bases 23          appeared satisfactory and later in the recommendation, you are 24          going to see at least in the overall recommendation that plant 25          specific information, of course, is desirable so that you are
                    -  .. ._              __ _ _ . . _ . - _ _        _ _____..~_ ___ _ _.____ _- _ -_____-                      -
 
i                                                                          .                                                                                        27 1              not talking generic.
2                                          You mainly are interested in that plant and not some 3              hypothetical plant.
4                                          Next we have the recommendations by Sandia.
5                                          MR. GLEASON:                      Next chart, please.
6                                            (SLIDE.)
7                                          MR. LEVINE:                      The recommendations go into the 8              standard review plan aspect and it basically brings up i
9              somewhat the same thing about the associated support systems j                  10                considerations and then the unreliability criteria which 11                primarily excludes areas like loss of Ac power or black-out i                  12                and also excludes loss of offsite power ought to be considered 13                in that particular SRP.
(                                                                                                    It is not in there now.
:                  14                                            I have already mentioned the unreliability criteria 15                as far as the other initiators are concerned.
16                                            The staff reviews of the PRAs themselves probably 17                and I think as we really talked it, it should more than ju t sa l
18                determination of just compliance.                                                      I think they need to go i
19                into them in a little deeper way rather than say done by the 20                number and what is this thing telling me and how does it 21                affect the overall aspects of the plant including what is 22                happening at the plant.
i                  23                                          That is the Sandia area.
24                                          MR. GLEASON:                        Charlie, if we could go back to six 1
25                again?
1 i.
        .g--.- --r                    --+.w--,,y.c-_
i.w                  ---w. -- - - -                      __, _ ,          .,-.,...~,.w_ _ .      .um__  __-,.y +. ,.eg um ,wr-e-,,,,----,,.w,,,.-w,  --,w-,.
 
28 1                              (SLIDE. )
      ~
i 2                              MR. GLEASON:    We did ask the staff and anyone else, 3          of course, about the PRA methodology and it is obvious that i
4          the staff does support it.                              It is obvious also that it has l
5          limitations but in essence, they believe it should be where 6          the case justifies it, it should be used to point the way to 7          more reliability.
8
,                                          We took a look at some other areas in which 9          additional reliability techniques could be used and Joe is I
10          going to be talking about this, will talk about this for a 11          minute.            Joe.
12 l
(SLIDE.)
13                              MR. LEVINE:    All right.                              Basically, the staff 14 authorized a NUREG/CR-4271 which I referenced in the document i
!        15          and it documents a lot of, I think, valuable techniques that 16          could be applicable. in this case, it was to the DOE, but it 17          certainly is not restricted to the DOE.                                              I will pass it around 18          for those of you that haven't seen it.
19 (Above-reference document was distributed to the 20          Commissioners.)
21                                MR. LEVINE:    I think this document does offer a lot 22          of techniques that could be tailored for the reactor power 23          industry.              As a matter of fact, some of them are.                                              Some of 24          them are things that you would think are already in place like 25          configuration management.
 
29 1                                                                  But in our discussion with Admiral Williams and one 2                      of the things that he is pushing very hard is to make sure
!          3                      that he does have a configuration management system in place l        4                      at Davis-Besse.                                      Without that, you don't know the status of 5                      the plant, you don't know what its configuration is and in 6                      fact, no one can really do anything unless they understand 7                      that fundamental.
8                                                                  The other areas like failure mode and effects 9                      analysis are techniques that we have used before in my l      10                        background and just to get a better understanding of the i
11                        causes of failures and something you can sit down and relate
!      12                        to people who have responsibility of the design and as a 13                        matter of fact makes you sensitive in the sense of the
;      14                      maintenance aspects of that item as well.
;      15                                                                    The qualification control is pretty well self 16                        evident and it is another one that Admiral Williams when we l
l 17                      were at Davis-Besse; mentioned as the first thing he wanted to 18                      do was to find out what the status of the qualification of the 19                      components are.
20                                                                  Now that looks that would be a straight forward 21                      thing but it is not.                                        After eight or ten years unless somebody 22                      pays attention to that, the item can get out of configuration 23                      and as a matter of fact how it is maintained might make the 24                      difference of whether it was really qualified in the sense of 25                      how it was built originally by the manufacturer.
 
30 1                      Failure reporting corrective actions sounds like 2  something, of course, that everyone does, but believe me it is 3  a very difficult task and it one that you have to pay very 4  close attention to but therein lies your history and your 5 performance indicators of telling you what your history is and 6 what people have done and basically you can go back on that 7 track and find out any time what has occurred.
8                    Maintainability analysis, in particular a nuclear 9 power plant where you are desirous to stay up and where in the 10  case of Davis-Besse they have in their license such things as 11  the ability to have one of the auxiliary feedwater pumps down 12    for some pre-determined amount of time and then the anxiety is 13  how quick can you restore.
14                      So having had a pre-determined type analysis of this 15  time that really pays attention to restoration, whether it is 16  restored in place or a like item, almost sounds like 17  motherhood but it is the type of planning that, I think, has 18  to be done to give yourself confidence.
19                    The other ones in terms of maintenance is straight 20  forward.              G&H are items that Jim Taylor is doing right now on 21  a selected scale and that is going in as I understand it and 22  comparing the as-designed configuration to the as-built and 23  has found quite a difference as I understand it in many cases 24  when we talk to them and I think you will see later we 25  certainly endorse that.
e --      , - - . - --          -
 
31
          .~.
1                  So that is just a few of the things.              The NUREG that 2        I handed out is a little more detailed and I think it would be i
3      useful to follow up on.
I                    4                  COMMISSIONER ASSELSTINE:      What kind of assumptions 5      were made in the PRAs that were done both by the company and 6        in our reviews of them about things like equipment reliability 3
7      and the level to which equipment was maintained in this 8      plant?    Did they assume that the equipment was all maintained 9        in a fairly high level?
10                      (At this point in the proceedings, Chairman o
11          Palladino exited the meeting.)
12                      MR. LEVINE:    Yes, sir. They gave some degradation
(          13          for that in terms of maintenance but the numbers as I say it 14          were very generic and as a matter of fact, in the 0611 and 15          0635 offered the numbers up to use as a pattern to go by and 16            that is the danger of using generic numbers rather than plant l                17            specific numbers. i
!                18                      COMMISSIONER ASSELSTINE:      How can you take a PRA and 19            make it fit the real world particularly in a situation like 20            this where you had a plant where we knew maintenance was a i
!                21            problem, had been a consistent problem for some time and where i
22            you see higher than normal equipment failures, that kind of 23            thing?
24                      MR. LEVINE:    I think the value of a PRA in that case 25            would not be the number.      It would be logic of putting down l
I
 
32 1 the information and utilizing the logic.      But there is a 2 caution and I think in most of the analyses, the caution is 3 there but no one pays a lot of attention to it, is " Don't use 4 that number in an absolute mode but look at it in terms of its 5 relative aspects" and I think that is the danger of using 6 those kind of numbers and people who become satisfied because 7  it fits their number.      They walk away satisfied whereas, in 8  fact, things may be in very bad shape.
9            COMMISSIONER ASSELSTINE:    Would you say based upon 10  what you saw of the situation at this plant that in fact the 11  situation was really much worse than those PRAs would indicate 12  in terms of the reliability of this system and the potential
(  13  for failure?
14            MR. LEVINE:    Yes, sir, I would. I don't think the 15  PRA had anything to do with it, in fact, almost irrelevant as 16  far as this particular plant.
17            COMMISSIONER ASSELSTINE:    And yet that was the basis 18  for basically not doing anything or arguing back and forth for 19  literally years?
20              (At this point in the proceedings, Chairman 21  Palladino re-entered the meeting.)
22            MR. LEVINE:    Yes, and i think they were arguing 23  about a specific rather than a generality.      In other words, 24  they were really looking at a diverse pump rather than looking 25  at, "Well, what about the pumps that were there already."        If
 
33 1 you have pumps, both diverse and steam powered none of which 2 may have been maintained, what good does it do?
3          COMMISSIONER ASSELSTINE:  that's right.
4          COMMISSIONER BERNTHAL:  Again, getting back to the 5 point that I was trying to make before, making a decision that 6 a plant should be shut down because of a serious hardware 7  question is a decision we have made many times in this Agency.
8            We find out something is wrong or something cracked 9  somewhere, there is, I guess, one of the latest was a shaft 10  crack in a certain class of plant which incidentally included 11  this one.
12            COMMISSIONER ASSELSTINE:  That's right.
13                                      We shut them down and ask
(                  COMMISSIONER BERNTHAL:
14  them to inspect. That is an easy decision. The tough 15  decision and the one that perhaps the commission itself has j    16  not exercised leadership on is how do you calibrate when you l
17  have an operation that is just not going very well, when the 18  SALP rating doesn't look very good, there is no readily l
19  identifiable hardware problem, there is no smoking gun that 20  Harold Denton can point to in regulatory terms and say that 21  this is just wrong and we have to get it fixed, that is a 22  decision that if we expect the staff "to belly up to the bar" 23  on that one, then the Commission has to be.willing to do that, 24  too, and I don't think we have ever done it.
25            We have just never really decided at what point is
 
                                              .. ._.                              _                                                                              .=            _      ..
34 I                1 the point where an operation's maintenance and general plant 2 operations are bad enough that we just shouldn't let them 3 continue running.                      We didn't do that here either.
4                        MR. LEVINE:                  I think that is going to be a very 5 subjective thing.
I                  6                        COMMISSIONER BERNTHAL:                                                                    It sure is.
7                        MR. LEVINE:                  No matter how many performance 8 indicators, I think when you --
9                          COMMISSIONER BERNTHAL:                                                                    That is exactly right.
10                          MR. LEVINE:                  -- when wise men gather together with 11  all the facts and I mean all the people, then I think you will 12  make the best decision that you know how to make.                                                                                                              But I think
(            13  it is not going to be based on some one thing.                                                                                                              It is going to j                14  be on this aggregate and it will be different at each time.
;                15                          COMMISSIONER ASSELSTINE:                                                                            That's right, yes.
16                          (SLIDE.)
17                          MR. GLEASON:                    Well, our recommendations are up there i
18  and I think they kind of speak for themselves.                                                                                                              We think there 19  was a long process, too long of a process, to review and act 20  upon the PRAs.                      I think it is fair to say that the issue came 21  up during a very, very busy post-TMI period when a lot of 22  other things were going on.
23                          As Joe has mentioned, there are a number of other 24  disciplines in addition to PRAs that can be evaluated as a 25  possible improvement.                                  That book that we handed out is just an
        , . - . .        - - - _ _ - . . - _        - - . . _ _ _ - - . . . _ ~ _ _ , _ - _ _ - . . - - , - . _ _ . _ _ . _ . - - - - _ _ . _ _ _ . _ . _ - -
 
35 1    example. The Division of Research does have out studies on 2    attempting to gather more reliability assurance methods.
3              Then finally we recommend t.3t at least a more, 4    perhaps a higher effort be given to the safety system 5    functional inspections. I understand I&E has referred this to 6    the regions. This is not a matter of regulation. It is to be 7    hoped that the utilities themselves will undertake this kind 8    of design overlook or design evaluation, if you will, safety 9    system evaluation because at least in the three plants that 10      the staff has done it, they have come up with -- changes have 11      been made and information that is disturbing which according 12      to the operators of the plant, they have been pleased to find
('  13      out about and they probably would not have found out about 14      them in the ordinary inspection process.
15                Once again, it is a matter of getting the utilities i
g            16      to undertake that kind of responsibility.
17                COMMISSIONER ASSELSTINE:    On the previous slide 18      where you are talking about configuration control problems, 19      did you get a sense for how widespread a problem that is?      I 20      guess the reason I asked is another problem plant told me not 21      too long ago that look, why are picking on me for 22      configuration control?    Nobody in an older plant has 24      a problem that is?                                                ~
;            25                MR. LEVINE:  I really didn't get a good sense of
 
_    _  _ = . . - _ - . . _      _ - . . _  -
J 36 1  that.      I have a suspicion that it is widespread.
,      2                  COMMISSIONER ASSELSTINE:                      Yes.
3                  COMMISSIONER BERNTHAL:                      It is not very hold.
4 4      ,
MR. LEVINE:          I think particularly when you get into 5  getting records, in fact, looking at SALP reports and asking 6  that question and I am certain that some of them do, but 7  really getting into that aspect is a very valuable input to 8  do. I know they are looking toward changing it.
9                  COMMISSIONER ASSELSTINE:                      Yes.
10                  MR. GLEASON:          If there are no other questions, we 4
11  will get into the third area which is a charge to take a look 12  at the licensee's management operation and maintenance 13  programs.
(
14                  (SLIDE.)
15                  MR. GLEASON:          This was an area that really required l
16  us to take a look at their operation from the beginning until 17  June 6 or June 9, 1985.                  We thought that the records showed I
18  that Toledo Edison made the ordinary management changes to get 19  into a nuclear mode of operation and separated its nuclear 20  functions o,ut in time.                                                                                .
21                  It appeared to respond favorably to the Region III 22  request for changes.                  It increased its personnel from the 23  figures of 340 to 590 in that period of time.                                        It was 24  intensively involved at the time of SLAP IV and the PEP 25  Program which is a $19 million dollar improvement program
 
37 1        which knows not only response to NRC's request for changes but 2        was a response to some of their own things that they are 3        trying to get done.
4                                                                                    CHAIRMAN PALLADINO:      Could I just ask you a question 5        with regard to organization?                                                                          There are a number of aspects to 6      this question of organization.                                                                          One may be that the people 7        brought in weren't quite as qualified as they might be but 8      sometimes you even get the most qualified people and the 9      organization chart looks good but the actual cross-ties and 10          opportunity for decision aren't really as strong as they might 11          be implied by the organization chart.
12                                                                                      Do you have any better feel in this case what it was
. 13          that led to really inadequate result from the organizational 14          change?
15                                                                                      MR. GLEASON:  It is a very difficult area to look 16          at, Mr. Chairman.
17                                                                                      CHAIRMAN PALLADINO:      I know and I appreciate that.
18                                                                                      MR. GLEASON:  It is not only difficult for us but 19          the staff, of course, finds it very, very difficult to look 20          at.
21                                                                                      In our discussion with Mr. Reed as I recall from 22          Commonwealth he indicated that there was an effort made to 23          change the manager at one of his plants, that some of the 24          regulatory staff felt was a very bad manager and he said that 25          he was one of his best managers.
 
38 1          So it is a subjective area. I don't know whether 2  the performance indicators are going to be much of a help in 3  this thing. I think there are times when if the same thing      l 4  keeps recurring then obviously the inspectors and the regional 5  people have to take a move but if it somebody at a very top 6  level, they have to go to the Board of Directors which is one 7  of our recommendations that comes out.
8            But we didn't get a feel. Pete, do you want to add 9  something?
10            MR. MORRIS:    Mr. Chairman, I don't think we detected 11  anything in the organization per se.      We did detect from 12  talking to the persons in Toledo Edison that there may have
(  13  been an attitude problem of upper management and I think that 14  is the one that is very difficult to deal with.
15            COMMISSIONER ASSELSTINE:    Your report had some 16  interesting little nuggets in it in terms of information one 17  of which was you referred to the substantial amount of money 18  that they had spent in the construction of other nuclear units 19  that they were involved in over time.
20            Was that supposed to send a message?    For example, 21  were they putting their effort and attention and resources 22  into Perry and Beaver Valley and skimping on Davis-Besse?      Has 23  that been part of the problem here?
24            MR. GLEASON:    It was one of the unresolved areas 25  that the group had. We asked the questions. We didn't get
 
39 1  any answers we could fix any conclusions on.      There was 2  testimony to the effect that as far as safety was concerned, 3 why they got the funds they requested.        All we were trying to 4 do is to at least point out that there is always that 5 possibility when they have an expenditure of that amount going 6 on to other plants when their own construction program is 7 essentially finished.
8            COMMISSIONER ASSELSTINE:    You also quoted I think 9 our regional administrator who said that when top utility 10  management is part of the problem, NRC inspectors find it more 11  difficult to delve into management issues.        How much of a 12  problem was the CEO?    Did he contribute to the attitude
(  13  problem of this utility?      Did he intimidate on coming forward 14  with requests for safety improvements?        Did he provide the 15  resources that were needed to get the job done?
16              MR. GLEASON:  We got testimony from the staff who l
17  were there at the time he was there that the resources
(
13  necessarily to do the job were there.        However, they did 19  indicate in areas of maintenance that they were lacking in the 20  necessary funds, that things would go on and they just 21  wouldn't get the funds.
22              There also wac ' testimony that when they had funds 23  committed toward certain kinds of improvement, a SALP would 24  come along and then the funds would be diverted to taking care 25  of the things that SALP wanted them to take care of.        So it is
 
40 1 a question that we just couldn't get a complete answer on.
2                  COMMISSIONER ASSELSTINE:              So none of you form any 3 opinions about the role that the CEO played?
4                  MR. GLEASON:        It is easy to form opinions, 5 Mr. Asselstine, but informed judgment is a different thing.
6                  COMMISSIONER ASSELSTINE:              all right.
7                  MR. MORRIS:        We didn't feel that we could second 8 guess people like Jim Keppler who were so close to the 9 management.            We did hear lengthy testimony from Mr. Keppler 10  and others about the upper management.                      There were some 11  symptoms in my mind, for example, an inadequate supply of 12  spara parts.
13                    COMMISSIONER ASSELSTINE:              Yes.
14                    MR. MORRIS:        There was a period of time when the 15  company had some financial problems and you look at a plot of 16  personnel versus time, it leveled off.                      There were some 17  indications that key people left the company and were not 18  replaced on time.
19                  There were some indications that contractor people 20  were used to some extent.                Of course, the contractor people 21  don't have the long term loyalty to the organization.
22                  COMMISSIONER ASSELSTINE:                Yes.
23                  MR. MORRIS:        So these are symptoms which we can't 24  draw firm conclusions on but I think the Region III certainly 25  did.
]
 
41 1            COMMISSIONER BERNTHAL:    Jim, I have to say that I 2 doubt very seriously if the day is going to come that very 3 many members of this five-member panel on this side of the 4  table to say nothing of our staff for whom it is even more 5 difficult are going to step forward and say, "You know, I 6 really don't like this or that manager or that small group of 7  two, three, four top management.      It is time to shut the plant 8  down because I don't like their management style."
9            I have to recall and I know you remember, too, that 10  we had a circumstance on this commission at one point where 11  there were one or two folks that were insisting that a plant 12  not be permitted to start up until exactly that problem was
(    13  remedied when at the same time the same management was running 14  another plant and nobody was willing to say that that plant 15  ought not to run any longer.
16              The point is, I think if you are looking for a way 17  to make an evaluation that would have led you to say that 18  Davis-Bessa or Rancho Seco perhaps should not be permitted to 19  run longer, I suspect that those evaluations have to be i
20  objective and in this particular case, those two cases and I 21  would like the panel's disagreement or agreement if they can 22  give it, the thing you probably could have looked at would 23  have been maintenance more than anything else.
l
!      24              If you had gone through and looked careful at 25  maintenance in those two cases, than you might have had a shot 1
 
42 1 at an objective valid judgment of whether this plant really 2 was in the shape that it should be to run.
3          Now that may indeed be a management problem. I am 4 not sure it matters which one it is though.
5          COMMISSIONER ASSELSTINE:  I guess what I am trying 6 to get at is a root cause analysis. I agree with you, Pete, 7  that when I was out at the plant shortly after the June 9th 8  event, one of the things I was told is you know, here is a 9  power plant, supposedly an operating power plant, we don't 10  have any valve packing material. We are out of it.
11            I was told that there was a large number of 12  equipment, instrumentation in the control room, that was out
[   13  of service literally for months prior to the June 9th event 14  because they didn't have the replacement parts. Now what is 15  the reason for that.
16            I think that is a fair question. Why is it and I 17  was told maintenance people in the plant weren't properly 18  trained, they didn't know what they were doing. They would 19  come out to pieces of equipment and they would say to the 20  operators, "What kind of a pump is this?"    The operators would 21  say, "You mean, I am the one that has to start this pump up 22  after you fixed it and you don't even know what kind of pump 23  it is."
24            Why did those things occur?  I think that is a fair 25  question and I think that in many respects the answer you will l
l
 
43 1 ultimately get when you look at these problem cases is there 2  was-a lack of management involvement in the process, a lack of 3 management support to doing the job right, not sending the 4  signal throughout the organization that we are going to take 5  care of these problems, not wanting people to come forward and 6 tell them we have these problems and we need some money to fix 7  them.
8            I think that is a fair question to ask and quite 9  frankly, I guess I am a little surprised and disappointed that 10  the response is, "Well, people had opinions about those things 11  but we didn't see that there was really enough information to 12  reach some informed judgments on those kinds of questions."
13            MR. GLEASON:    You asked, Mr. Asselstine, you asked 14  the members of the Ad Hoc Group whether they had any 15  opinions.
16            COMMISSIONER ASSELSTINE:    Yes.
17            MR. GLEASON:    I think opinions are one thing. Our 18  judgment is in the report. We asked that question. We asked 19  that very question and we just didn't get back -- they said 20  that they got what they needed.
21            COMMISSIONER ASSELSTINE:    I guess the question that 22  I am asking and I guess you don't have an answer is, did 23  you find enough information to reach an informed judgment of 24  how significant a role management was in the condition of this 25  plant and the quality of the operations of this plant over a
 
44 1  substantial period of time?                                          i 2            I realize you reached a conclusion just on this one
{
3  event. You couldn't necessarily trace it to that one but in 4  terms of the overall performance and I guess you don't have 5  enough information to reach that judgment.
6            CHAIRMAN PALLADINO:    There are management companies 7  and this may be one of the follow-up items if the Commission 8  decides, there are management companies that make this area of 9  expertise and if that is an important question, then maybe a 10    group such as that should be called in.      I am not suggesting 11    that as the answer.
12              But I think we have to explore what follow-up we are
(    13    going to make based on the report that the Ad Hoc Group was 14    able to come up in the time frame that they had at hand.
15              COMMISSIONER ASSELSTINE:    My sense is the problem is 16    pretty much solved at Davis-Besse now largely because of some 17    very fundamental changes in management that have taken place.
18              CHAIRMAN PALLADINO:    How do we know?
19              (At this point in the proceedings, Commissioner 20    Roberts exited the meeting.)
21              MR. GLEASON:    That change in management was a result 22    of the prior chief executive officer's decision before the 23    event.
24              COMMISSIONER BERNTHAL:    Let me make one other 25    comment though if I could, Joe.      It is interesting, Jim, that
 
                                  . _ ~ . .          _    _.    -              .
45 l
1    in your searching for a way to make these judgments ahead of 2    time which I agree with, that would be great, if we could 3    decide ahead of time which one is going to have the bad 4    incident next, it sure would be nice to be able to make a good 5    judgment.
6              You ticked off a list of items that were objective 7    indicators.              Indeed if we really had our hands on the 8    maintenance question, we could have gone in and seen exactly 9    the things that you mentioned, that this and that and the 10    other thing were not being done.
11                It is not entirely clear to me that we have to 12    answer the question then of whether management caused it.              It 13    is enough to say that this is the way it is and the question 14    that we need to answer for ourselves is should the plant be 15    permitted to continue running.
16                If it happens repeatedly, then maybe you also draw a 17    conclusion about the management.              It is a difficult thing to i          18    judge.
19                COMMISSIONER ASSELSTINE:            Yes, but it seems to me    i 20    that you have one question is, should the plant continue to 21    run or not and you pay well reach the conclusion, indeed I i
i    .
22    mistakenly reached that conclusion in this particular case, 23    that they could and that they were adequately addressing the 24    problems. You still need to understand what the root causes 25    are to make sure they get fixed, whether it can be done while
 
46 1 the plant is running or whether the plant has to be shut down.
2          CHAIRMAN PALLADINO:    Let me suggest that we move 3 on. I am not saying these are not important items to discuss 4 but I think getting the overview will enhance our discussion.
5          MR. MORRIS:  Mr. Chairman, I don't want the 6 Commission to feel that we don't have some opinions on the 7  management of the plant prior to the accident.              In my mind 8 there is absolutely no doubt that management was responsible 9 for the condition of that plant and the way in which it was 10  operated.
i 11            (At this point in the proceedings, Commissioner 12  Roberts re-entered the meeting.)
13            MR. RATHBUN:  I agree with that. Let me just add 14  one note. When we met with Admiral Williams, as I recall in a 15  luncheon session as we were leaving Davis-Besse, he said that 16  the one good thing, I think he called it the silver lining 17  that seemed to result form this incident was that it did as 18  best I recall change attitudes in such a way as to provide the 19  funding that he believed they needed to do the job right.                      ,
20            CHAIRMAN PALLADINO:    All right. Good.
21            MR. GLEASON:  If I could pick up, as I indicated 22  there was a very heavy oversight activity going on during this 23  six year period. There was something like nine management 24  meetings, six enforcement conferences. The study group which 25  was formed after the event by Region III has pointed out that
 
47 1  the review board which is required by the tech specs were 2  repeatedly cited for failure to review violations and 3  procedures.
4          They were too busy with the tech specs requirements 5  according to their testimony.
6          As far as maintenance was concerned, there were over 7  1,300 items pending on June 9th outage although most of them 8  were balance of plant. We all recognize that the challenge to 9  safety systems comes often from balance of plant items and 10  therefore they do have some safety significance.
11            The employees testified that at the time of the 12  accident itself or at the time of the event itself, there were
(  13  60 to 70 yellow tag items needing maintenance attention in the 14  control room itself.
15            The SALP ratings during that period showed for the 16  last three periods showed in maintenance they got a category 17  three and they also; reported there were deficiencies in some 18  quality assurance areas.
19            In the last SALP report which was early 1984 of the I    20  11 areas, 11 functional areas, there were five three 1
21  categories and three of the five were getting worse than i    22  three. They were declining with targets going away, getting
!    23  to be a larger problem.
24            I might say maintenance was one of the areas that 25  was getting better, the three going in a better area.
 
48 1              We took a look at the oversight or the regulatory 2  requirements on management.                  There really isn't much that 3  deals in a precise fashion with management.                        The obligations 4  are kind of indirect but there are a lot of oversight 5  activities that impact on how management performs in operating 6  and maintaining nuclear power plants.
7              In the report on page 58 and 59 we list all of those
          .M    and there are just many, many areas of oversight mechanism, 9  interpretation, communication mechanisms and enforcement 10    actions.
11                We wara queried by or we were talked to or discussed 12    with some of the Davis-Besse personnel some of the problems,
  /      13    the operating problems, that come from the oversight process 14    and they did mention that there were a lot of problems in the 15    security area, the physical security barriers slowed down 16    access. In fact, it slowed down access during the event l
17    itself. There was a lot of problems in the fire protection 18    area and they did say that at times you had to pay so much 19    attention to what the regulatory staff was telling you that                                      .
20    you really didn't know what you could do or what you were 21    supposed to do with respect to the plant itself.
22                COMMISSIONER ASSELSTINE:                  Jim, on the security 23    issues, I think that is a valid concern having walked down the 24    route as I am sure you guys do, too, saw those grates and 25    chains. One question I guess I have always had is how much of l
l
 
1 49        j 1 that was really in our requirements and how much of it was in 2 the manner in which the licensee chose to implement the 3 requirements?
4                      I guess I have never quite understood, for example, 5 did they have to have the chains and the padlocks, could they 6 have had a wire with a seal that could easily have been broken 7  in an emergency to get in that area quickly for safety?
8                      MR. GLEASON:  It is a very good question because as 9  you know each plant devises its own procedure and then gets it 10  qualified and we really didn't get into that.
11                      COMMISSIONER ASSELSTINE:            All right.
12                    MR. GLEASON:    We thought we would not just accept
(  13  some of this testimony from the Davis-Besse people about the 14  interface problems with operating and we did take a look at 15  the study that was done by the staff after the O'Riley Report, 16  NUREG-0839, that took 12 utilities and did a very exhaustivs i    17  study of plant personnel, operating personnel, plant managers, 1
18  about what the impact of regulatory actions was and their 19  conclusion came out was that it did, that the pace and nature l
20  at that time in 1981, the pace and nature of regulatory l
l    21  actions did create a potential safety problem of unknown 22  dimensions.
l 23                  Well, in order to bring that up to date and see 24  about its validity, we did go and ask four other utility 25  representatives who I have already mentioned to come in and i
1 i
 
o  .
50 1 their testimony was similar in nature, that they protested the 2 prescriptiveness of the regulatory procedure.
3          They talked particularly about the testing, the 4 surveillance requirement and they said it takes a plant or a 5 utility which has a lot of resources and able to challenge 6 something, if it were a smaller plant, you would just tend to 7 go ahead.
8          There were a lot of very unfavorable comments 9 expressed. If you ever get some time you might want to read 10 some of those interviews about the regulatory staff.          Some of 11 them in the human area about the kind of treatment they get or 12 had gotten in a couple of instances.
13          We just thought it was a matter that we recognize --
(
14 we can get into the recommendations here.
15          (SLIDE.)
16          MR. GLEASON:        We have recognized that in your policy 17 and planning guidance for 1986 that the Commission itself has la called for a review of the regulations and to take a look l
l    19 whether some of the regulations could be eliminated without l
20 compromising safety.
21          I want to emphasize very clearly to the commission l
l    22 that our recommendations in support of this is geared towards 23 increasing safety and not decreasing it in any way but one can l
24 certainly hypothesize a situation where the oversight process 25 gets so heavy that it in itself becomes a safety factor.
 
51 1            If that occurs, why then of course the burden of 2  safety has shifted away from where it should be, the 3  operators, back to the utility or back to the regulatory 4  staff, the NRC.
5            Another recommendation and when we get into a 6  situation like Davis-Besse, we think that there ought to be 7  access made by the NRR management and the regional director's 8  directly to the Board of Directors itself because if you have 9  a chief executive officer, you can't do anything with that 10  individual if he is weak and if he is the root cause of the 11  problem, do you bring it to the attention and we think that 12  ought to be done.
(  13              COMMISSIONER ASSELSTINE:  Jim, at one point, I 14  think, in the report you mentioned the number of changes that l    15  had been made to the auxiliary feedwater system over time as 16  one of the things you had heard, "Well, you know, we made a 17  lot of changes to this over the years."
18              If at the outset either in initial licensing or 19  certainly when come of the lessens of TMI bscame protly clear, 20  either we had insisted or the company had done voluntarily a 21  major improvement on the auxiliary feedwater system, would 22  that have really obviated the need for all of these smaller 23  changes that sort of preoccupied everyone's attention for 24  years and years?
25              MR. GLEASON:  Pete, would you like to answer that?
 
1
  .  .                                                                                      1 52 1                  MR. MORRIS:    We can only speculate but I would guess 2      certainly in part.
3                  COMMISSIONER ASSELSTINE:      Yes. All right.        I gather 4      the $70 million dollars would buy a heck of an auxiliary 5      feedwater system.
6                  MR. MORRIS:    In fact, that would be safety grade and 7      seismically qualified.
8                    (Laughter.)
9                  MR. GLEASON:    We were fairly impressed with the 10    maintenance program that INPO has devised.            We were 11      recommending in some way if the staff could take advantage of 12    this, we realize INPO's problem of confidentiality and we just 13      don't know how this could be done but we certainly think that 14      they have laid out a very extensive program for the utilities 15      and they intend to credit the various utilities against it.                  I 16      think Davis-Besse's maintenance program is to be accredited i
17      sometime the end of,this year.
18                COMMISSIONER ASSELSTINE:        Did the INPO review find 19      the same kinds of Weaknesses and problems that our inspection 20      program was turning up?          Were they pretty consistent?                  '
21                MR. GLEASON:        Yes.
22                COMMISSIONER ASSELSTINE:        Did you ask why the INPO 23      program was not effective in bringing about change within this 24      organization until something serious happened or do you have 25      any thoughts on why that might be the case?
I
                                      -          ~              . . - - - , -.
 
53 1                MR. GLEASON:                  Go ahead.
2                MR. MORRIS:                There were, I believe, t lest several l
3      reviews by INPO and the INPO reviews are generally in                                                                        j 4      functional areas.
5                COMMISSIONER ASSELSTINE:                                        Right.
6                MR. MORRIS:                There is also a corporate review and I 7      don't know that at the time that that was made, in fact, it 8      may have been made after the incident, so to back up a little 9      bit, the findings in the functional areas were generally quite 10        consistent with Region III inspection findings.
11                  On the corporate findings, I don't think there was 12        any real criticism.
13                  COMMISSIONER ASSELSTINE:                                        If INPO was aware, I take
(
14        it over a span of several years, about the poor level of 15        operations looking at the functional performance at the plant, 16        why weren't they able to bring about meaningful changes?                                            Did 17        they try?                      i 18                  MR. MORRIS:                If you recall the way in which INPO 19        works with the utility, the utility itself responds with a 20        plan.                                                                                                                        '
21                  COMMISSIONER ASSELSTINE:                                        Right.
22                  MR. MORRIS:              That takes time and it takes time to 23        implement it and so it takes a couple of cycles to see whether 24        or not progress is being made.                              I think in this case there 25        just wasn't enough time to really measure whether progress was l
 
54 1    made against INPO's evaluation.
2              COMMISSIONER ASSELSTINE:  So it literally takes a 3    period of five years is what you are saying?
4              MR. MORRIS:  I would 1 say a minimum of two to 5    three.
6              COMMISSIONER ASSELSTINE:  All right.
7              MR. GLEASON:    The last recommendation is that the 8    and I think that we have talked about it before or mentioned 9    before is the integrated living schedules should be 10    encouraged. I think they have been tried. This is a 11    mechanism, as you know, that takes the things that the plant 12    wants to do and the things the staff requires be done and
{        13    tries to coordinate them into a meaningful program of 14    prioritization.
15              I think they have about 14 or 15 utilities involved 16    now. We get the sense that most of the utilities are holding l          17    back to see how these go before they commit themselves.
I 18              CHAIRMAN PALLADINO:  Does this plant have an 19    integrated living schedule?
20              MR. GLEASON:  It does, yes. It has something -- it 21    has submitted something but what the status of it is, I am not
;          22    sure. Davis-Besse has.
23              CHAIRMAN PALLADINO:  I am sorry, I missed that.
24              MR. GLEASON:  I said, Davis-Besse has submitted an 25    application of some kind for an integrated living schedule but t
 
55 1 the status of it, I am not sure of.
2            MR. MORRIS:          I don't think it had been formally 3 approved by the staff at the time of the incident.
4            CHAIRMAN PALLADINO:          All right.
5            COMMISSIONER ASSELSTINE:          Would a living schedule 6 have speeded up the third pump or slowed it down or had no 7 effect?
8            MR. GLEASON:          It probably would not have had any 9 effect looking at the state it'was in.
10            COMMISSIONER ASSELSTINE:          I gather that the 11  prevailing view at the time was that the third pump was not a 12  high priority item.
13            MR. GLEASON:          It got to be decided that it wasn't a 14  high priority at that time.
15            COMMISSIONER ASSELSTINE:          Even though the potential 16  contribution of an auxiliary feedvater problem was very high in relation to sort;of the Commission's bench = ark for core 17 18  melt down acceptability.
19            MR. MORRIS:          Of course, the third pump was not on 20  the schedule until the high energy line break problem arose in 21  the fall of 1984.
22            COMMISSIONER ASSELSTINE:          All right.
1 __                  _ _ _ _..__ _ _ _
23            (SLIDE.)
l        24            MR. GLEASON:          The last area, Mr. Chairman, I will be l
l        25  very brief, was our review of the IIT effort at Davis-Besse.
l
 
56 1      They had some problems. They had problems with lawyers.
2                COMMISSIONER BERNTHAL:  That's funny, so do we!
3                COMMISSIONER ASSELSTINE:  Everybody has problems I
i          4      with lawyers.            ,
5                MR. GLEASON:  Everybody has problems with lawyers, 6      even lawyers have problems with lawyers.
7                MR. MORRIS:  Including this group.
8                (Laughter.)
9                MR. GLEASON:  Particularly this group.
10                  (Laughter.)
11                  HR. GLEASON:  I am off my track here now.
12                  (Laughter.)
13                  COMMISSIONER ROBERTS:  That is what lawyers will do 14        to you.
15                  MR. GLEASON:  Anyway, they had problems with 1G        transcripts, how to handle it. They were brought into being 17        at the same day that the SECY-208 paper which is a paper that 18        recommended the IIT program from the staff was presented to 19        the Commission. They had it in hand but they did not feel 20        bound by it. They didn't do any interacticn on the event as 21        far as the staff was concerned which we thought was a mistake.
22                  Industry, we have talked to, feels a little left out 23        of this process. They apparently were not consulted before 24        the program was put to bed. They feel that they have an 25        obligation to maintain plant safety and then when an event l
 
57 1 occurs, they have to stand by and just quarantine equipment s 2 it is ordered by the Region.
3              I understand some workshops are going to be 4 undertaken by AEOD as soon as the program is completely 5 formalized.      The procedures, I think, are pretty far along by 6 now. We hope that they will straighten this problem of 7  representation out.
8            I don't think you can exclude.      If a person from a 9  utility wants to be represented, I don't think you can exclude 10    him from the session.        You can exclude the degree of 11    participation that he makes.
12                In any event, we thought that they did a fairly good
('    13    job at Davis-Besse.        We didn't think they put in their report 14    the justification for their principal conclusion but 15    nevertheless, we think in the time period they had and with 16    the complexity of the problem that they had that their 17    performance was certainly adequate.
18                The following-on IITs did de a little investigation 19    with the staff to some extent, not as completely I think as 20    hrobablyshouldbe. We do think that this area of trying to 21    confront the charge of how do people investigate themselves l        22    even though you have separate groups doing f.t is one that is a 23    very serious one and it is one that is very, very difficult to I
24    defend against.
25                In the life and breath of an agency, paople work
 
58 1  with various people at different times so it gets to be 2  probably the case more than the exception that somebody is 3  investigating an event where there has been some interaction 4  and somebody that he has worked with.
5              I recall the statement made by the chairman of the 6 Rancho Seco event, I believe, which he said something to the 7  effect where they went back and criticized the staff, he says, 8  "Well, I hope they didn't mind or I hope they weren't too 9 sensitive" and he says, "It is a hard thing to do."
10                  So in the light of all of that and with the light, 11    of course, of understanding that people are attempting to 12    continue to press for an independent safety organization, we 13    think that probably that -- well, two things.        We think that 14    the investigation of the staff ought to be made as part of the 15    IIT to see whether any of their activities were part of the 16    root cause but in order to get that out of the ordinary 17    workings of the agency, we think this ought to be done above
,      18    the EDO's level, ought to be an agency that reports directly 19    to the Ccamission and we suggest the Office of Inspection and 20    Auditing to carry out that task.
21                  We recognize that-they do not have the technical 22    expertise but they can call on it just as they did, in fact, 23    in connection with Davis-Besse.
24                  (SLIDE.)
25                  MR. GLEASON:  I think we should say one final word
 
59 1  about the follow-up program that was done as a result of the 2  Davis-Besse event. We thought that was a very healthy 1    3  exercise. All program managers were directed to conduct an 4  in-depth and searching re-appraisal of the effectiveness of 5  their programs and keeping in mind the lessons of Davis-Besse 6  and we think a lot of good things have flowed out of that.
7            I guess that about concludes our report, 8  Mr. Chairman, and we would be glad to respond to any other 9  questions you have.
10            CHAIRMAN PALLADINO:  Thank you very much.                        We very 11  much appreciate the efforts that you have made and the report 12  that you have produced. I found it a very good report, at i
13  least in my mind, and I thought very helpful.
14            There is one lesson that comes through and I know 15  I have repeated it several times already this afternoon, but I 16  think it is a very important lesson.
17            As a matter of fact, I remember in lectures I gave 18  my students at the university, I said, "You know, President 19  Truman had a sign on his desk that says, 'The buck stops 20  here.'"    But I used to ask them, "Have you ever thought about 21  where the buck starts because an executive can cope with 22  issues that are brought before him but the worst kind of 23  issues are the issues that deserve his attention that he 24  doesn't know about."
25            I think that lesson applies in this case.                        The
 
60 1    organizations knew it and there was a history that knew it but 2    it is not clear to me that as the management changed, this 3    issue was before it and we have all sorts of tracking systems 4    but we need some other way to make sure that the issues that 5    we are dealing with are the important ones and I think you 6    emphasized that.                                                That is why it took us so long on the first 7    item.
8                                                Let me see if my colleagues have any comments or
!              9    questions and then I do want to take a minute or two to 10    address what follow-up action we need or want.                                                    Tom, do you 11    have comments?
12                                                COMMISSIONER ROBERTS:            Just thank you, gentlemen,
(        13    for what obviously was quite an undertaking.                                                    Thank you very 14    much.
l            15                                                CHAIRMAN PALLADINO:            Jim.
l 16                                                COMMISSIONER ASSELSTINE:            I think I pretty much                                        ,
17    covered my questions already.                                                I just agree with you, Joe, and 18    extend my special thanks particularly, Joe, to you and Guice 19    for your participation in this.                                                I think the review benefited 20    by having an outside perspective with people of your
* 21    particular capabilities or abilities.
22                                              MR. LEVINE:              Let me say a point on that.                  I have 23    retired from NASA on June 3rd but I learned a lot of things 24    that I want to take back to my colleagues.                                                The interchange of 25    information, I think, is going to be very useful and I will l
i
 
61 1  do that.
2            CHAIRMAN PALLADINO:      You mean there is something we 3  are doing that might be right?
4              (Laughter.)
5            MR. MORRIS:    I won't comment on NASA.
6            CHAIRMAN PALLADINO:      Fred.
7              COMMISSIONER BER2iTHAL:    I just want to echo the 8  sentiment on what I think was a job well done and a good look 9  at some of our institutional processes.                  If I could prevail on 10  each of you for a minute, you can answer or not as you choose, 11  but there is sort of a melange of recommendations here.
12              If I ask you the single most important thing that in
(  13  your judgment came out of that that we ought to pay attention 14  to in one sentence, what would it be?                    Would any of you be 15  willing to pinpoint?      Is there something that stands out in 16  your mind as a paramount issue?                                              .
17              MR. LEVINE:  I think that in reality you can have a 18  regulatory commission but if you don't have a very strong 19  utility with strong management and a good attituda and an 20  attitude towards safety, I dare say your job is impossible and I
l    21  what comes out of this type thing is that if we look at all i
l    22  the regulations and the things and how much you can look at l    23  things, that is a long sentence by the way, but I understand 24  you like long sentences --
j    25              (Laughter. )
{
 
62 1          MR. GLEASON:    I don't know where he got that.      He 2  didn't get that from us.
3            COMMISSIONER BERNTHAL:      He must have read something 4  I wrote.
5            MR. LEVINE:  But I dare say that the buck does 6  really stop at the utility and there is where it has to be --
7  it has to be the right attitude not just at the manager level 8  but every level below and you have to feel that 9  responsibility. The systems have to be in place.      The 10  training has to be in place but that is where it has to be, at 11  least that is what I got out of it.
12            COMMISSIONER BERNTHAL:      Anybody else want to
(  13  comment?
14          MR. TINSLEY:    Yes. I promised not to talk today but 15  maybe I can make just a quick comment.        I have had the benefit 16  of both a military career and working over at the FAA and I
,    17  would like to say first, I am very impressed with the quality 18  of the people that we had to work with and the people that we 19  interviewed on the staff.
20          Where it is good to take the kind of look that we 21  are doing, don't be too hard on yourself.        I think when you 22  look at your basic charter and what you have to do, very few 23  people bat 100-percent in the business of safety and you have 24  done what your overall mission is and you should take credit 25  for that and. I think every chance you get.
 
63 1              My message is, is there a way that we really can                '
2      convey to the American public how well you are doing, the kind 3      of things that you-are doing to continue to protect in the s
4      future and also tc make them aware of the need that we have 5      for the energy.in the future.
6                I think it is important that we have an educational 7      p'ogram r    to really let people know'what is going on.
8                COMMISSIONER BERNTHAL:          We should have let him talk t
9      earlier.            ,
10                CHAIRMAN PALLADINO: .Thank you.                            #
11                  (Laughter.)
12                CHAIRMAN PALLADINO:      All right.      Any others? Lando.
(          13            -
COMMISSIONER ZECH:      No. Thank you very much. I 14      just also would likofto thank the panel for an excellent job i
15      and I apprecitte very sincerely yodr contribution.
16                MR. GLEASON:    I would likefto say, Commissioner j            17      Bernthal, as I indicated before that this experience has been i
18      a great education for me and as anybody is are pleased with 19      that kind of an opportunity.        The thing that I' drew out of 20      this experience is not in the report, I guess.
21                But I guess it produces my great sympathy for people 22      that have to regulate in this area and for people who have to 23      be regulated in this area.      I think there is almost.an 24      impossible situation that has been created because as you know 25      as you try to wrestle with this multiplicity of design l
b
 
64 1 problem, as I have looked over the inspector's manual book you 2 could put ten inspectors in every plant and you still would 3 not assure safety.
4          Essentially looking at it from the staff's point of 5 view, how can they do this impossible job when you have any 6 time with the prescriptiveness or with the surveillance 7  testing which was brought about because you couldn't get at 8 the components and liable to leave something turned the wrong 9  way after the last test and this often times causes a problem.
10            I think somehow there has to be a better working 11  together of this agency and the utilities and I think a lot of 12  it is coming about with INPO and NUMARC and so on but it is a
  . 13  tough ball game and you are out in left field because you 14  don't apparently have any champions up in the Congress any 15  more and I think it is very, very difficult and I think it is 16  very unfair and I just have to commend you for carrying on 17  this responsibility.
18          I don't know how you do it. That is what I brought 19  out of this experience.
20          COMMISSIONER BERNTHAL:    I appreciate that.
21          CHAIRMAN PALLADINO:    Thank you. Let me ask the 22  Commission or at least let me first state what I feel we      _
23  should do. We certainly don't want to let the lessons that 24  you have given to us be lost and I think follow-up action in 25  one form or another is needed and if you would agree, I would
 
l 65 1  propose that the Secretary write an SRM based on the 2  discussion in this meeting tasking the staff to review the 3  report and prepare an action plan or a plan of action that it 4  would plan to undertake and recommendations that they may make 5  for the Commission and present the action paper to the 6 Cummission for its review and do this in a reasonable time 7  frame which I am not prepared to suggest at the moment.
8          That is the very least I would hope would come out
                                                                  ~
9 of this but I am open to other suggestions.
10            COMMISSIONER ZECH:  I think it is a good idea.
11            COMMISSIONER ASSELSTINE:    Sounds fine to me.
12            CHAIRMAN PALLADINO:  All right.                    Then why don't we
[
13  proceed that way. Let me indicate that we have an affirmation 14  session that was supposed to be held at 3:30.                      I have been 15  informed that my staff wants to talk to me about it before I 16  am ready to vote. So I am going to suggest that we adjourn 17  now, take a ten-minute break and then come back for 18  affirmation.
19            COMMISSIONER ASSELSTINE:    Good.
20            CHAIRMAN PALLADINO:  Thank you very much gentlemen.
21  We stand adjourned.
22            (Whereupon, the Commission meeting was adjourned at 23  3:40 o' clock p.m.,  to reconvene at the Call of the Chair.]
24 25
 
I 2                                    REPORTER'S CERTIFICATE 3
4                        This is to certify that the attached events of a 5        meeting of the U.S. Nuclear Regulatory Commission entitled:
6 7        TITLE OF MEETING: Briefing by Davis-Besse Ad Hoc Review Group (Public Meeting) 8        PLACE OF MEETING:                    Washington,              D.C.
9        DATE OF        MEETING: Friday, June 6, 1986 10 11        were held as herein appears, and that this is the original 12        transcript thereof for the file of the Commission taken 13        stenographically by me, thereafter reduced to typewriting by 14        me or under the direction of the court reporting company, and 15        that the transcript is a true and accurate record of the 16        foregoing events.
17                                    ;
la                                              -  -- --                -      -
hkL% 2)
Marilynn M. Nations 19 20 21 22        Ann Riley & Associates, Ltd.
23
                ~
24 25
                                                                                  ~
 
    -    -                                    6/5/86 SCHEDULING NOTES TITLE:    BRIEFING BY DAVIS-BESSE AD H0C REVIEW GROUP SCHEDULED: 2:00  P.M., FRIDAY, JUNE 6, 1986 (OPEN)
DURATION:  APPROX l-1/2 hrs MEMBERS:  JUDGE JAMES GLEASON (NRC), CHAIRMAN JUDGE PETER MORRIS (NRC)
DENNIS RATHBUN (NRC)
JOSEPH H. LEVINE (NASA)
H. GUICE TINSLEY (FAA)
DOCUMENTS: - DAVIS-BESSE AD HOC REVIEW GROUP REPORT DATED 5/2/86
              - VIEWGRAPHS G
e
                                                      +
l l
h
 
l l
,                        COMMISSION BRIEFING
;                                BY i            THE AD H0C REVIEW GROUP i
ON THE DAVIS-BESSE INCIDENT a
j i
 
1 f
l i
:                            CHARTS l
\
: 1. EXAMINE TE (REGlLATORY) PROCESS CONCERNING
!        TE AUXILIARY FEEDWATER SYSTEM PRECEDING TE EVENT.
!  2. EXAMINE PRE-EVENT PROBABILISTIC ASSESSENTS l      0F THE AFWS.                          -
i
!  3. EXAMINE LICENSEE'S MANAGEMENT., OPERATION APO l      MAINTENANCE PROGRAMS.
l  14 . EXAMINE INCIDENT INVESTIGATION TEAM ACTIVITY AT DAVIS-BESSE.
l l
 
l                                        -
i THE AD H0c GROUP i
! MEMBERS:            H. GUICE TINSLEY (FAA)
JOSEPH H. LEVINE (NASA)
DENNIS K. RATHBUN (NRC) i PETER A. MORRIS (NRC)
JAMES P. GLEASON (NRC) l f
l  PROCEDURE:          DOCUMENT REVIEW INTERVIEWS VISITS
: 1.        THE REGULATORY PROCESS CONCERNING THE AFWS PRECEDING THE EVENT CONCLUSIONS A.          EXTENSIVE AND DETAILED INTERACTIONS AND ACTIVITIES B.            RECURRING PROBLEMS AND CHANGES C.            NO COMPLETE RESOLUTION BEFORE INCIDENT                  .
D.            EARLIER RESOLUTION MIGHT HAVE BEEN TECHNICALLY JUSTIFIABLE E.          GENERIC VS. SPECIFIC APPROACH COULD HAVE DELAYED AFWS MODIFICATION DECISION
        -,...,.m-  _ _ _ _ . -_-._..._,.m.                            _ . . _ . - _ _
 
O i
RECOMMENDATIONS A. QUARTERLY MEETINGS OF EDO WITH REGIONAL ADMINISTRATORS AND TOP HQ l      STAFF          ..
B. PROJECT MANAGERS TO VISIT SITES AND LICENSEE MANAGEMENT PERIODICALLY l
C. IMPLEMENT INTEGRATED TRACKING AND l
l      MANAGEMENT SYSTEM l
D. DEFINE GENERIC VS. SPECIFIC l
PROMPTLY FOR DECISIONMAKING l
l j
4
_ _  _ _ - _      A
 
l t
i    2. PRE-EVENT PROBABILISTIC ASSESSMENTS i
I  i i '
CONCLUSIONS l
A. DIFFERING RELIABILITY ANALYSES l j APPARENTLY DELAYED FINAL DECISION l i          ON NEW FW PUMP l
1 i i      B. PRAS SHOULD INCLUDE ASSOCIATED SYSTEMS AND PLANT-SPECIFIC DATA
. i BASE i
C. PRAS SHOULD BE SUPPLEMENTED WITH QUALITATIVE RELIABILITY TECHNIQUES TO GAIN CONFIDENCE l
 
I                                                                    f 4                                                                  O 1
i RECOMMENDATIONS l  A. ESTABLISH TIMELY AND EFFECTIVE PROCESS TO REVIEW AND ACT UPON PRAS B. EVALUATE OTHER MANAGEMENT AND RELIABILITY DISCIPLINES TO IMPROVE 4      RELIABILITY C. PRIORITY TO SAFETY SYSTEM l      FUNCTIONAL INSPECTIONS AND OUTAGE i
!      SYSTEM MODIFICATION INSPECTIONS l
1 l
4 4
: 3.          LICENSEE'S MANAGEMENT, OPERATION AND MAINTENANCE PROGRAMS CONCLUSIONS                      _ _ _ _
A.          TOLEDO EDISON CHANGES IN ORGANIZATION AND PROGRAMS NOT SUFFICIENT TO PREVENT INCIDENT B.          NRC OVERSIGHT AND ENFORCEMENT ALSO NOT SUFFICIENT l
C.          CNRB OVERALL AUDIT FUNCTION NOT EFFECTIVE D.          BALANCE OF PLANT ITEMS ARE IMPORTANT TO SAFETY E.          MAINTENANCE PROGRAM DEFICIENT; PREVENTIVE MAINTENANCE PROGRAM NOT SYSTEMATICALLY                                                        .
DEVELOPED AND MANAGED F.          REGULATORY BURDEN MAY HAVE BEEN DETRIMENTAL TO PLANT SAFETY i
  - ~ - . . - ,---    , . - , -              ---,,y--.    - - -. - - - - - - - -  - - - - - - - - ,  - - - - - - - - - - - - - - - - -          -
 
l i              RECOMMENDATIONS i
l j  A. PERFORMANCE-BASED VS. PRESCRIPTIVE
!        REQUIREMENTS i
!  B. NRR MANAGEMENT AND REGIONAL ADMINISTRATORS MEETINGS WITH LICENSEE BOARDS OF DIRECTORS l  C. NRC POSSIBLE UTILIZATION OF INP0'S MAINTENANCE PROGRAM 1
i D. INTEGRATED LIVING SCHEDULES ENCOURAGED
 
1 1
: 4. THE DAVIS-BESSE INCIDENT INVESTIGATION                                              '
TEAM ACTIVITY
;                                                    CONCLUSIONS A. MANDATE ADEQUATE l
i l                      B. PRE-EVENT INTERACTIONS SHOULD BE INCLUDED i
l                      C. TRAINING AND INFORMATION NEEDED FOR i                            PARTICIPANTS AND/OR INDUSTRY 1                      D. DAVIS-BESSE IIT PERFORMANCE ADEQUATE i
          !            E. ED0 FOLLOWUP PROGRAM ADEQUATE i
{
 
i J
i            RECOMMENDATIONS I
!    A. EXPEDITE DEVELOPMENT OF i
j        IMPLEMENTING PROCEDURES B. PROVIDE FOR PARTICIPATION OF
;        OUTSIDE-EXPERTS
!    C. ASSIGN OFFICE OF INSPECTOR AND j        AUDITOR FOR NRC PRE-EVENT INTERACTIONS j    D. SPECIFY ROLES OF COUNSEL AND
!        ADVISORS
    ! E. ACCELERATE INVESTIGATIVE TRAINING 4
 
l                                                  l
;                                  NUREG-1201 i
  . Report of the                                  '
;&  Independent Ad Hoc Group l    for the Davis-Besse Incident i
i U.S. Nuclear Regulatory Commission p+=~n,,
a
: s.    /
 
NUREG-1201 l
                          ''Z                  _ _ . _ . - _ _          _ _ - . . _
                                                                                                                                            ~l. .
:                      Report of the Indeaendent Ad Hoc Group for tie Davis-Besse Incident 4,                                                                                                                                      l
                                                                                                                                                  )
l
                                              ~.___.Z______                                                                              - __
Manuscript Completed: May 1986 l
Date Published: June 1986 i
U.S. Nuclear Regulatory Commission Washington, D.C. 20666
                      %                    /
l          s.
l l
  . . - _ _ _ . , . . . . . . . . . . . , ~ . - - . - - . - - - - . . .            - - . - . . . - . _ - - _ . - . - . . . - _ ,_
 
l ABSTRACT The Nuclear Regulatory Commission established an independent Ad Hoc Group in January 1986 to review issues subsequent to a complete loss of feedwater event at Davis-Besse Nuclear Power Station on June 9, 1985, including the NRC Incident Investigation Team (IIT) investigation of that event. The Commission asked the Group to identify additional lessons that might be learned and from these to make recommendations to improve NRC oversight of reactor licensees. To fulfill its charter, the Ad Hoc Group examined the following:    (1) pre-event interactions between the licensee and NRC con-cerning reliability of the auxiliary feedwater system and associated systems; (2) pre-event probabilistic assessments of the reliability of plant safety systems, NRC's review of them, and their use in regulatory decisionmaking; (3) li-censee management, operation and maintenance programs as they may have contributed to equipment failures and NRC oversight of such programs; and (4) the mandate, capabili-ties of members, operation, and results of the NRC Davis-Besse IIT, and the use to which its report was put by the regulatory staff.
4 111
 
i                                                                                                                                                                        .
e CONTENTS
        ,                                                                                                                                                                        Page
      ,                      Abstract ..............................................                                                                                              iii Davis-Besse Independent Ad Hoc Group ..'................                                                                                              vii l                          Acknowledgments ....................................... viii Acronyms ..............................................                                                                                                ix 1                      EXECUTIVE
 
==SUMMARY==
.................................                                                                                1 Background ........................................                                                                                1 Ad Hoc Group Mandate and Methodology ..............                                                                                1 Davis-Besse Regulatory History ....................                                                                              3 Ad Hoc Group Conclusions and Recommendations ......                                                                              3
;                                                                  1. Pre-event Interaction Between Toledo
,                                                                      Edison and NRC Concerning the Auxiliary
!                                                                      Feedwater System ..........................                                                                    4
!                                                                  2. Davis-Besse Reliability Assessments .......                                                                    5
: 3. Contributions of Toledo Edison's Manage-ment, Operation, and Maintenance Programs to Equipment Failures .....................                                                                    6 l        ..
<                                                                  4. NRC Incident Investigation Program ........                                                                    7 i
2                      INTRODUCTION ......................................                                                                              9 3                      PRE-EVENT INTERACTION BETWEEN TOLED0 EDIS0N AND NRC CONCERNING THE AUXILIARY FEEDWATER SYSTEM .....                                                                              11
;                                                  Regulatory Process - Pre-event ....................                                                                              11 iv
            -    . _ _ _ _ . - . _ _ . - _ - - . = _ _ , _ - - _ _              , - , - . . _ _ , . . _ _ - _ - . . - _ _ - . _ _ , _ - _ . - - _ _ . , _ . _ . _ _ , -          -
 
Page The Davis-Besse Maintenance Program ...............                                        32 The Davis-Besse Quality Assurance Program .........                                        33 Davis-Besse Plant and Safety Performance ..........                                        34 Organization for Nuclear Management ...............                                        37 Regulatory Oversight ..............................                                        38 Impact of Regulatory Oversight ....................                                        39 Conclusions .......................................                                        43 Recommendations ...................................                                        44 6 NRC INCIDENT INVESTIGATION PROGRAM ................                                        45 Background for the Incident Investigation Program ...........................................                                        45 Mandate and Instructions for Incident Investigation Teams (IITs) ........................                                        45 Capabilities of IIT Members .......................                                        46 IIT Operational Procedures ........................                                        47 Use of the Davis-Besse IIT Report by the NRC Staff .............................................                                        49        i Follow-on Incident Investigation Team Reviews .....                                        49 Conclusions .......................................                                        50
    ,  Recommendations ...................................                                        50 4
i i
i vi
                                                                  .,,_,--..--.<.-s-    . .,- ---      - ~ , ,
                                      ,--,,,.y. ., ,  .-,,-_.--.-y                  _,
 
l I'
Page Licensing Actions for the Davis-Besse Auxiliary Feedwater System and Associated Systems ...........                                                                                                    12 Advisory Committee on Reactor Safeguards ( ACRS)
Review ............................................                                                                                                  21 Conclusions .......................................                                                                                                  21
  ,    Recommendations ...................................                                                                                                  22 4 DAVIS-BESSE RELIABILITY ASSESSMENTS ...............                                                                                                    23 Pre-event AFWS Probabilistic Reliability Assessments .......................................                                                                                                    23 Toledo Edison AFWS Reliability Analysis (EDS Nuclear, Inc.) ...........................                                                                                                  24 Brookhaven Review of EDS Analysis .............'                                                                                                24 Toledo Edison AFWS Reliability Analysis (Impell Corp.) ................................                                                                                                  25 Analyses  ....................................y Ad Hoc Group Review of Davis-Besse Reliabilit
                                                                                  ......                                                                      25 Use of Reliability Probabilistic Analysis in Regulatory Decisionmaking .........................                                                                                                    28 Additional Qualitative Reliability Techniques for Regulatory Decisionmaking .....................                                                                                                    28 Conclusions .......................................                                                                                                    29 Recommendations ...................................                                                                                                    30 9
5 CONTRIBUTION OF TOLEDO EDIS0N'S MANAGEMENT,
  ,    OPERATION, AND MAINTENANCE PROGRAMS TO EQUIPMENT FAILURES ..........................................                                                                                                      31 The Toledo Edison Nuclear Program .................                                                                                                      31 i
y
 
DAVIS-BESSE INDEPENDENT AD H0C GROUP s
James P. Gleason, Chairman, Administrative Judge, Atonic Safety and Licensing Board Panel, Nuclear Regulatory Commission Joseph H. Levine, Chief, Reliability Division, Directorate of Safety, Reliability, and Quality Assurance, Johnson Space Flight Center, National Aeronautics and Space Administration Peter A. Morris, Ph.D., Administrative Judge, Atomic Safety and Licensing Board Panel, Nuclear Regulatory Commission Dennis K. Rathbun, Deputy Director, Office of Policy Evaluation, Nuclear Regulatory Commission H. Guice Tinsley, Technical Program Officer, Federal Aviation Administration 4
I l                                                  vii
 
ACKNOWLEDGMENTS
  , The Davis-Besse Ad Hot Group wishes to extend their appreciation for the excellent support provided by the NRC Staff relative to the background of events at Davis-Besse.
The Group extends its thanks for their valuable cooperation and information to officers of the Toledo Edison Company and to officials and executives of other industry and utility organizations.
We also wish to acknowledge our appreciation to members of the Atomic Safety and Licensing Board Panel for their valuable service as a peer review group:
Jerry Harbour, Ph.D., Administrative Judge Jerry R. Kline, Ph.D. , Administrative Judge Morton B. Margulies, Administrative Law Judge Ivan W. Smith, Chief Administrative Law Judge In addition, we wish to acknowledge the excellent support given to the Ad Hoc Group by the NRC Atomic Safety and Licensing Board Panel staff with respect to their excellent administrative, technical, and secretarial assistance. .In particular, we commend the dedicated efforts provided by the Group's Executive Assistant, Mr. Charles J. Fitti.
t i e viii
 
ACRONYMS
  , ACRS    Advisory Committee on Reactor Safeguards (NRC)
AE0D    Office for Analysis and Evaluation of
  '            Operational Data (NRC)
AFWS    Auxiliary Feedwater System ASB    Auxiliary Systems Branch (NRC)
B&W    Babcock & Wilcox BNL    Brookhaven National Laboratory B0P    Balance of Plant CAPC0  Central Area Power Coordination Group CE      Combustion Engineering CEO    Chief Executive Officer CNRB    Company Nuclear Review Board CRGR    Committee for Review of Generic Requirements (NRC)
DVR. Deviation Report EDO    Executive Director of Operations (NRC)
EFIC    Emergency Feedwater Initiation & Control 4
EPRI    Electrical Power Research Institute FMEA    Failure Modes and Effects Analysis FSAR    Final Safety Analysis Report I&E    Office of Inspection & Enforcement (NRC)
ICS    Integrated Control System IIP    Incident Investigation Program (NRC)
!    IIT    Incident Investigation Team (NRC)
  -  INP0    Institute of Nuclear Power Operations LER    Licensee Event Report MFWS    Main Feedwater System NMSS    Nuclear Material Safety & Safeguards (NRC)
NRC    Nuclear Regulatory Commission NRR    Office of Nuclear Reactor Regulation (NRC)
          ,                ix
 
NSAC  Nuclear Safety Analysis Center NSSS  Nuclear Steam System Supplier NUMARC Nuclear Utility Management and Resource Committee NURE0  Nuclear Regulatory Commission Report OIA    Office of Inspector and Auditor (NRC)
PAT    Performance Appraisal Team (NRC)
    . PORY  Pilot Operated Relief Valve PRA    Probabilistic Risk Assessment PSA    Probabilistic Safety Assessment
  ,  PWR    Pressurized Water Reactor QA    Quality Assurance RES    Office of Nuclear Regulatory Research (NRC)
SALP  Systematic Assessment of Licensee Performance SER    Safety Evaluation Report (NRC)                '
SFRCS  Steam and Feedwater Rupture Control System SMUD  Sacramento Municipal Utility District SRP    Standard Review Plan (NRC)
TMI    Three Mile Island USI    Unresolved Safety Issue 9
X
 
1    EXECUTIVE
 
==SUMMARY==
 
===Background===
The Davis-Besse Nuclear Power Station, operated by the Toledo Edison Company, underwent a complete loss of feed-
  , water event on June 9, 1985. The day following the event, the Executive Director for Operations (ED0) of the U.S.
Nuclear tigationRegulatory)
Team (IIT Commission to Davis-Besse  (NRC) to sent    an Incident ascertain              Inves-the facts, to identify the probable causes of the event, and to form conclusions and make recommendations as the basis for corrective actions. The results of its, investigation are documented in " Loss of Main and Auxiliary Feedwater Event at the Davis-Besse Plant on June 9, 1985" (NUREG-1154).
Ad Hoc Group Mandate and Methodology The Nuclear Regulatory Commission established an independent Ad Hoc Group in January 1986 to review issues subsequent to the loss of feedwater event at Davis-Besse and the Da-vis-Besse IIT's investigation.          The Commission asked the              ,
Group to identify any additional lessons that might be                        i learned from the incident, and from these to make recommen-dations a50ut how NRC internal procedures and oversight of reactor Vicensees may be improved. By this and other reviews,;and by implementing the recommendations arising from the:n, the Commission proposes to reduce the possibility of future similar occurrences.          To fulfill its charter, the Ad Hoc Group was asked to undertake the following studies:
: 1. Examine the process of analysis, review, and interac-tion between the licensee and the NRC that took place
!        preceding the event concerning the reliability of, and
  -      the need and schedule for modification of, the Da-vis-Besse auxiliary feedwater system and associated systems; and make recommendations as to how the regula-
  .      tory process may be improved in light of the findings resulting from this examination.
: 2. Examine pre-event probabilistic assessments of the reliability of the Davis-Besse plant safety systems, the NRC review of these assessments, and the use to which these analyses were put in the regulatory decision-making process; and make recommendations as to how the use of this sort of reliability analysis in the regula-tory process might be improved.
1
: 3. Examine the licensee's management, operation and maintenance programs to the extent that they may have contributed to the equipment failures that caused or exacerbated the incident; examine the NRC's require-ments for, and oversight of, such licensee programs; and_make recommendations as to how the NRC may improve its regulatory processes and its oversight of reactor licensees in these areas.
: 4. Examine the mandate, capabilities of members, opera-                    ,
tion, and results of the Davis-Besse incident investi-gation team, and the use to which its report was put by the regulatory staff; and make recommendations as to how the incident investigation process may be improved.
* The Commission directed that the review not be a vehicle for determining whether Davis-Besse could be operated without undue risk to the public health and safety.              The Commission further for the specified    that incident on    the the  Group part of Toledonot assess Edisonresponsibility (the licensee )
or the NRC staff.
In implementing its review, the Group interviewed principal NRC Headquarters and Regional personnel, the Chairman of the Advisory Committee on Reactor Safeguards (ACRS), Toledo Edison corporate and departmental managers, officials from the industry's Institute of Nuclear Power Operations (INP0) and from Babcock & Wilcox (B&W), and executives from four other nuclear power utilities. The testimony of these utility executives was solicited to broaden the Group's perspective on NRC's IIT program, on utility management issues, and on the impact of regulatory requirements on plant operations.      In site visits, the Group examined Toledo Edison's management, operations, and maintenance programs.
The Group also reviewed relevant correspondence, reports, and other documents on Davis-Besse matters for the period 1977 to the present.
The various probabilistic analyses made of the auxiliary feedwater system (AFWS) were analyzed for the Ad Hoc Group by Sandia National Laboratories.          The Group also solicited          -
the views of B&W, Toledo Edison, and the NRC staff about probabilistic studies that were performed for the AFWS following the accident at Three Mile Island.                                  .
Since the Incident Investigation Program is new to NRC, the Group considered it essential to compare the practices and procedures for the Davis-Besse IIT incident investigation with those of the subsequent San Onofre and Rancho Seco IIT investigations. Accordingly, the Group interviewed the NRC Team Leaders for these IITs and reviewed relevant documenta-tion.
2
 
Davis-Besse Regulatory History Davis-Besse was licensed to operate in 1977.      Averaging 7,7 trips (unscheduled shutdowns) yearly, Davis-Besse averaged            '
an annual capacity factor of approximately 45% until June 9, 1985. Although some of its outages can be traced to NRC          '^
Three Mile Island backfit requirements, the major contribu-tors were. equipment failure.s and personnel errors. Plant operations .have been marked-by frequent deficiencies in maintenance' ef forts and procedural and . Technical Specifica-tion violations, as reflected in NRC's Systematic Appraisal of Licensee Performance (SALP) reports. The NRC inspection effort at Davis-Besse was in excess of 1,500 work days and required over fourteen management or informal conferences prior totthe June 1986 incident.
As a result of the incident, the NRC staff and Toledo Edison have engaged in an extensive evaluation of their respective                        ,
responsibilities in assuring opetational safety at Da-vis-Besse. For the NRC, this process has required not only implementation of a substantial number of generic and plant-specific actions, but an appraisal of the relevant programs in the Offices of Nuclear Reactor Regulation (Nkk),
Inspection and Enforcement (I&E), Analysis and Evaluation of Operational Data (AE0D), and Nuclear Regulatory Research (RES), as well as for its Region III office. For Toledo Edison, it resulted in a nuclear staff reorganization, the authorization to hire additional personnel; a complete review of;the facility's safety-related systems prior to restart, and extensive improvements in training programs and' procedures. The cost to both organizations has been sub-stantial:  for NRC approximately $1.5 million, to date r and for Toledo Edison $71.5 million, a figure exclusive of power                            .
replacement costs.
In its 1986 Policy and Planning Guidance document, the Commission expressed its concern about unnecessary regulato-ry burdens and the Agency's volume of regulatory require-l ments. This year, in establishing a set of strategic goals, the Commission stated its intention to improve the regulato-
    ,  ry climate in which the nuclear industry operates, and to                    ~
complete a comprehensive review of NRC' regulations.      This report, by examining the extensive interaction between NRC and Toledo Edison prior to the incident, hopefully contrib-i utes to a continuing review of the status of that regulatory framework.
Ad Hoc Group Conclusions and Recommendations                    ,
Based on its review of issues subsequent to the June 9, 1985 incident at Davis-Besse, the Ad Hoc Group has arrived at the following conclusions and recommendations in the four areas specified in the Group's-mandate.
3
 
i
: 1. Pre-event Interaction Between Toledo Edison and NRC        l Concerning the Auxiliary Feedwater System Conclusions Extensive and detailed regulatory interactions and activi-ties took place concerning the AFWS at Davis-Besse between NRC and Toledo Edison from the licensing of the plant in 1977 through the June 9, 1985 incident.
                                                                  ~
The AFWS and related controls experienced recurring problems involving components and required a number of design chang-es, such as the addition of dynamic brakes on the pump      ~
turbine governors and flow indication in the control room for both steam generator AFW inlet lines. Toledo Edison made appropriate changes, including installation of a diverse power supply to one of the AFWS trains (for the        l motor-operated valves), that were required before the second    l fuel cycle. The staff approved a license for Davis-Besse,    l even though it lacked diverse power to the AFWS pumps, a        i condition unchanged up to the incident.
NRC's post TMI-2 evaluations of the Davis-Besse AFWS identi-fied the need for short-term and long-term modifications.
However, NRC did not require installation of a 100-percent capacity, motor-driven startup feedwater pump until Toledo Edison committed to its installation in September 1984, a
NRC did not believe that the Davis-Besse AFWS, as it existed before the incident, was sufficiently reliable. This conclusion was based largely on the lack of diverse power to the pumps and the lack of full capacity of the existing startup pump. Earlier requirements for suitable modifica-tions of the AFWS might have been justified technically, even though not required by the Commission's rules.
By focusing on a generic solution to the decay heat removal question, both the ACRS and the staff may have contributed to an unreasonable delay in resolving the specific weakness in the Davis-Besse AFWS. This finding does not suggest that generic solutions are not desirable where feasible. Ana-    -
lysts should exercise caution, however, in seeking solutions to generic problems when they unduly delay specific solu-tions at individual plants.                                  .
Recommendations Regional Administrators should meet with NRC Headquarters
;    management to review the performance of each nuclear power plant and licensee in their region at least quarterly, or more frequently as needed. The Group strongly endorses the current plans of the Executive Director for Operations (ED0) to implement such a program. The ED0 should make prompt l
l 4
1
 
l I
decisions to resolve problems and to establish appropriate schedules for completing their resolution.
Project Managers (with appropriate technical support) should visit nuclear power plants on a periodic basis (perhaps quarterly) to communicate directly with plant management and utility licensing officers.
The Group strongly endorses the E00's current development
    ,    and implementation of the integrated tracking and management system to assure effective management monitoring and resolu-tion of safety and licensing issues. Such a system might
    '    have been of assistance prior to the 1985 incident at Davis-Besse.
The staff should decide and communicate the results of decisions to relevant staff and licensees promptly as to whether an issue is plant-specific or generic.      Such deci-sions should be made or endorsed by the EDO and action plans should be promulgated and executed expeditiously.
: 2.      Davis-Besse Reliability Assessments Conclusions The conflicting assumptions, methodologies and findings in licensee and NRC staff reliability analyses, and considera-tion of the quirements (proposed Committee for Review of Generic Re-CRGR) memorandum AFWs, were factors in delaying the final decision on the installation of a diverse electric motor-powered auxiliary feedwater pump. Another factor delaying a final decision was the staff's delay in generic resolution of the decay heat removal issue, Unresolved Safety Issue (USI) A-45.
Improvements in probabilistic analyses of safety systems can be achieved by inclusion of important associated systems and a more defensible plant-specific data base.
l Additional qualitative reliability techniques and measures
    ,    over and above probabilistic analyses could be useful to in-crease confidence in the safety of nuclear power plant oper-ation. Improvements in the probabilistic analysis process
    ,    will be more useful in NRC regulatory decisionmaking if they are augmented by information gained from other qualitative management and reliability techniques, such as configuration management, failure modes and effects analysis, and other disciplines discussed in Section 4 of this report.
Recommendations NRC should establish a timely and effective process to review reliability analyses requested of licensees, particu-l                                        5 l
l
 
larly where it is determined that such analyses will be used in regulatory decisionmaking.
NRC should evaluate the use of qualitative management and reliability disciplines as a means of increasing confidence in the day-to-day performance of nuclear power plant licensees.
I&E should give priority to the conduct and promotion of safety system functional inspections and outage system                                                                                                                                                                                                            .
modification inspections.
: 3. Contributions of Toledo Edison's Management, Operation,                                                                                                                                                                                                    .
and Maintenance Programs to Equipment Failures Conclusions The number of organizational changes made by Toledo Edison in its pre-event nuclear mission and programs to enhance reactor safety performance were not sufficient to prevent the June 9, 1985 incident; neither was NRC oversight and enforcement effective in preventing the incident.
It was not apparent that Toledo Edison's Company Nuclear Review Board (CNRB) performed its overall audit function of plant safety effectively.
There were deficiencies in the effectiveness of the manage-ment and oversight of plant operations which had been recognized in NRC's SALP evaluations.
The Group recognizes that balance of plant items are impor-tant to safety.
The pre-event maintenance program at Davis-Besse was charac-terized by many weaknesses and deficiencies. The pre-event preventive maintenance program was not systematically developed and managed.
Compliance with the substantial, growing volume of prescrip-tive regulatory requirements may have acted to reduce rather                                                                                                                                                                                                      -
than increase plant safety.
Recommendations                                                                                                                                                                                                                                                  .
The NRC should shift emphasis away from detailed, prescrip-tive requirements toward performance-based requirements.                                                                                                                                                                                                      A systematic, continuing review of NRC's regulatory require-ments embodying the full scope of regulatory oversight is needed to ensure that these requirements are coherent, consistent, and act to improve plant safety.                                                                                                                                                                                                      Responsibility for this function should be assigned to a specific office.
6
 
NRR management and Regional Administrators should meet with the licensee's Board of Directors when a plant's deteriorat-ing performance warrants.      The purpose of such        meetings would be to discuss the adequacy of the licensee's activi-ties to protect the health and safety of the public.          It would also provide the Board with an opportunity to express its views on the effectiveness of the current regulatory process.
NRC should take advantage of INP0's programs to assess licensee's maintenance management programs to the extent reasonable and practical.
The staff should improve its follow-up on licensee correc-tive actions.      Licensee " integrated living schedules" should be encouraged.
Resolution of the "important to safety" issue, and its application to balance of plant (B0P) items in existing, as well as future plants, deserves high priority.        (The Group understands that I&E has res least part of this problem.)ponsibility for resolution of at
: 4. NRC Incident Investigation Program Conclusions The mandate for Incident Investigation Teams is adequate for conducting NRC incident investigations.
The Davis-Besse IIT report would have been enhanced if the team had been instructed to examine pre-event NRC-licensee interactions.
There is need for NRC to conduct seminars or workshops to inform licensees in advance of the fundamentals of an NRC incident investigation.      (The Group understands that such a program is being considered by AE00.)
The Davis-Besse IIT members possessed adequate technical
, expertise to comply with the requirements necessary to perform their investigative task.        Th'e Group endorses proposals that IITs receive incident investigation training.
The Davis-Besse IIT report effectively described the se-quence of events of the June 9, 1985 incident. However, the report's observation that Davis-Besse had a history "of evaluating operating experience related to equipment in a superficial manner," was not supported in the report.            The conclusion that the underlying cause of the main and auxil-ia'ry feedwater event was the licensee's lack of attention to detail in the care of plant equipment was also not supported in the report.
7
 
The EDO Action Plan following the incident made adequate use of IIT report findings and conclusions._ The Action Plan is
                                            ~
commendable since it also included the requirement for the NRC staff to reappraise,its programs, planning, and actions based upon lessons learned from the Davis-Besse incident.
Unless organizations such as utilities, INP0, EPRI and reactor vendors are involved in the formulation of and are familiar with IIT procedures, they may not be willing or prepared to participate in future investigations.              .
Recommendations
                                                                  ~
Expedite the development of detailed procedures for the formation, training, operation, and reporting requirements of future IITs. These procedures should clearly define the (a) scope of the investigation and its schedule; (b) mode of operation for the team; (c) legal constraints and rights of licensees and employees, including NRC employees; (d) quarantining of equipment, with clearly defined roles for the licensee and the Region; and (e) completion of the assignment. These procedures should be developed and coordinated with the nuclear power industry and Agency personnel should meet with them to explain the role of IITs and how they will function.
Participation on IITs of members from INP0, EPRI, vendors, other utilities, and Federal and State agencies with appli-cable technical expertise, when appropriate, should be encouraged.                            ,
The Commission should assign NRC's Office of Inspector and Auditor (0IA) to investigate pre-event interaction between the NRC staff and the licensee as it may be relevant to the root cause of the event.
The NRC manual chapter and other appropriate procedures should specify guidelines concerning the role of counsel or other advisors for personnel interviewed by an IIT.
The IIT incident investigation training program should be      -
accelerated and consideration given to extending some of this training to Augmented Inspection Team candidates and other I&E staff members.                                        .
8
 
2  INTRODUCTION The Davis-Besse Nuclear Power Station, Unit 1, operated by
  . the Toledo Edison Company, is located on Lake Erie in Ottawa County, Ohio, approximately six miles northeast of Oak Harbor, Ohio. Toledo Edison is a part of the Central Area
  , Power Coordination Group (CAPCO) which is responsible for planning additional generating capacity in the CAPC0 service area. CAPC0 service areas cover northern and parts of central Ohio and sections of western Pennsylvania. Other CAPC0 members include the Cleveland Electric Illuminating Company, Duquesne Light Company, Ohio Edison Company and Pennsylvania Power Company. The Davis-Besse plant is jointly owned by Toledo Edison (49 percent) and Cleveland Electric Illuminating Company (51 percent), with Toledo Edison responsible for its operation. Toledo Edison and Cleveland Electric Illuminating Company have recently merged into a new holding company, Centerior Energy Corporation, which will operate a service company for the two operating utilities.
In January 1980 the CAPC0 companies terminated plans to construct Davis-Besse Units 2 and 3 and Erie Units 1 and 2.
Nonetheless, Toledo Edison's annual construction expendi-tures have been over $200 million per year in the 1980's.
Most of these costs are attributable to the continuing construction of CAPC0 nuclear generating units (Perry Units 1 and 2 and Beaver Valley Unit 2), of which Toledo Edison owns 20 percent.
Davis-Besse underwent a complete loss of feedwater on June 9, 1985. The day following the event, the Executive Direc-
!    tor for Operations (ED0) of the U.S. Nuclear Regulatory Commission (NRC) sent an Incident Investigation Team (IIT)
  -  to Davis-Besse to learn what happened, to identify the probable causes of the event, and to formulate conclusions and make recommendations for corrective actions. The
  . results of its investigation are documented in " Loss of Main
!    and Auxiliary Feedwater Event at the Davis-Besse plant on l
June 9, 1985" (NUREG-1154).
The Nuclear Regulatory Commission established an independent Ad Hoc Group (Group) in January 1986 to review other issues relating to the loss of feedwater event at Davis-Besse and the Davis-Besse IIT's investigation. The review was to identify any additional lessons that might be learned from the incident, and from these to make recommendations about
.                                  9
 
how NRC internal procedures and oversight of reactor licensees may be improved. To fulfill its charter, the Group was asked to review activities and make recommenda-tions in the following areas:
: 1. The interaction between Toledo Edison and NRC preceding the event concerning the auxiliary feedwater system (AFWS),
: 2. Pre-event probabilistic analyses of Davis-Besse safety        .
systems, NRC reviews of these analyses, and the use to which they were put in regulatory decisionmaking,
                                                                  ~
: 3. The extent to which Davis-Besse management, operations, and maintenance programs may have contributed to equipment failures that caused or exacerbated the event, and NRC requirements for and oversight of such programs, and
: 4. The mandate, operation, membership capabilities and results of the Davis-Besse IIT and the uses made of its report by the NRC staff.
In conducting its review, the Ad Hoc Group interviewed key NRC Headquarters and Regional personnel, the Chairman of the Advisory Committee on Reactor Safeguards (ACRS), Toledo Edison corporate and departmental managers, officials from the industry's Institute of Nuclear Power Operations (INP0),
representatives from Babcock & Wilcox, and executives from four other nuclear power utilities. The views of these executives was solicited to broaden the Group's perspective on NRC's IIT program, on mismanagement at nuclear utilities, and on the impact of regulatory requirements on plant                !
operations.        The Group compared practices and procedures for  '
the Davis-Besse IIT investigation with those of the San              ;
Onofre and Rancho Seco IIT investigations.        In site visits,    '
the Group examined Toledo Edison's management, operations,          l and maintenance programs. Additionally, the Group reviewed          i relevant correspondence, reports, and other documentation on        i Davis-Besse for the period 1977 to date.                            !
The various probabilistic analyses made for the auxiliary            l feedwater system (AFWS) were analyzed for the Ad Hoc Group by Sandia National Laboratories. The Group also solicited          -
                                                                    )
views on the probabilistic studies from Babcock & Wilcox, Toledo Edison officials, and the NRC staff.
The Commission directed that the Group's review not be a vehicle for determining whether Davis-Besse could be operat-ed in the future without undue risk to the public health and safety. Evaluating responsibility for the incident was also        ,
not within the purview of the Group.                                '
10 l
 
3    PRE-EVENT INTERACTION BETWEEN TOLED0 EDIS0N AND NRC CONCERNING THE AUXILIARY FEEDWATER SYSTEM
  - Regulatory Process - Pre-event This section provides an extensive chronology describing        j
  . specific events directly or indirectly pertinent to the        1 Group's review.                                                ,
l The staff identified the need to modify the Davis-Besse        j auxiliary feedwater system ( AFWS) when the plant was li-censed. While Toledo Edison made a number of changes over the years to improve reliability of the system, it resisted making major modifications until an unanalyzed safety question was identified in the fall of 1984.      Probabilistic reliability studies on the AFWS had been previously per-formed by Toledo Edison, by Babcock & Wilcox (B&W), and for the staff by Brookhaven National Laboratories (BNL).      The staff made no decision on resolving the issue while these studies were being evaluated.      Toledo Edison finally pro-posed installation of a full-capacity, motor-driven startup AFWS pump to resolve an unanalyzed safety question which affected system reliability and this resolution satisfied the staff's concern. The Group, based on its review, reached several conclusions and recommends that the staff act to resolve similar identified problems expeditiously and to communicate more effectively among its organizational components and with the licensee.
The regulatory process on the Davis-Besse AFWS involved the kinds of actions and 1 9 teractions between the following(Toledo licensee          Edison) and NRC :
* Reports of licensee events;
* The shutdown order following the TMI-2 accident;
* Applications for amendments to the operating license; 1
The Institute for Nuclear Power Operations conducted several evaluations of Davis-Besse operations, the results of which the staff was generally aware through exchanges of information between the NRC Regional inspectors and Davis-Besse personnel.
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* NRC requests for information and analyses by Toledo Edison and its responses;
* Review, evaluation and approval by NRC of requests for license amendments; Inspection by NRC onsite inspectors;
* Inspection by NRC Region III inspectors;
* A performance appraisal team (PAT) inspection;
* Management and enforcement conferences                    .
between Toledo Edison management and Region III management; Meetings between Toledo Edison staff and NRC staff; Systematic Appraisals of Licensee Performance (SALPs); and
* Civil penalty recommendations.
Licensing Actions for the Davis-Besse_ Auxiliary Feedwater System and Associated Systems The original AFWS was ess'entially a safety-grade system.
Both AFW pumps were driven by steam turbines, with only ac power available to the motor-operated valves in the two trains. The NRC staff recognized that the system was susceptible to common-cause failures.      As a license condi-tion, Toledo Edison was required to provide de power to one train of the AFWS at the plant's first scheduled refueling outage. The license condition was removed by Amendment No. 33 in October 1980 after Toledo Edison made the modifi-cation.
From initial startup until the incident on June 9, 1985, Davis-Besse had recurring problems with the AFWS and related controls. These problems involved components such as pressure switches and turbine governors.      Davis-Besse made a -
number of design changes, including the addition of dynamic brakes on the pump turbine governors and flow indication instruments in the control room for both steam generator AFW      -
inlet lines. Following TMI-2, Toledo Edison made a number of re-evaluations on its own, or at NRC's request, of the reliability of the AFWS, which necessitated a number of licensing amendments:
License Amendment 63, October 26, 1983, permitted removal of speed switches and interlocks to valves for the AFW turbines.
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Amendment 68, May 30, 1984, modified Davis-Sesse Technical Specifications to require that a :ninimum of two channels of AFW flow be operable for each steam generator.                        ,
Amendment 82, December 20, 1984, allowed AFWS operability to be determined without consideration of the status of the startup feedwater pump during startup (i.e., the startup feedwater pump could be
      ,          inoperable).
License Amendment 83, January 8, 1985, imposed three
      '        operational restrictions on the use of the startup feedwater pump to avoid hazards to the AFW pumps.
This amendment was a consequence of Toledo Edison identifying high and moderate energy lines in the AFW pump rooms whose failure had not been analyzed.
e Their failure could jeopardize the operability of either AFW pump from the effects of jet impingement, pipe whip, flooding and environmental conditions.
The amendment included these restrictions:
isolation outside the startup feedwater pump /AFW area of the startup feedwater pump suction, discharge and turbine plant cooling water piping, when the startup feedwater pump is not in operation, and Toledo Edison will install a startup feed-water pump, associated piping, and valves, to remove the hazards to the AFW pumps before commencing Cycle 6.
The original Davis-Besse Technical Specifications (1977) contained one Limiting Condition for Operation of the AFWS:
        "Two independent steam generator auxiliary feedwater pumps and associated flow paths shall be operable." Revision 3 of the " Standard Technical Specifications for Babcock & Wilcox (B&W) Pressurized Water Reactors (PWRs)," published in July 1979, contained the following Limiting Condition:
At least three independent steam generator auxil-iary feedwater pumps and associated flow paths
      .                shall be operable with:
l                      Two auxiliary feed pumps capable of being powered from separate emergency buses, and one feedwater pump capable of being powered from an operable steam supply system.
i i
Since Davis-Besse was licensed and operating, this require-ment did not apply to the plant's AFWS.
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The following chronology records numerous meetings, memoran-da, and analyses about the Davis-Besse AFWS involving NRC's Office of Nuclear Reactor Regulation (NRR), Toledo Edison
;                                and others prior to June 9, 1985.      I&E's Region III staff played little or no role in these interactions.                  It is also clear that the NRR staff did not appear well informed about the extent of the Regional staff's concerns regarding Toledo Edison's performance.      The Ad Hoc Group examined these activities in detail in forming its overall appraisal of the regulatory process.                                                                .
Following TMI-2 in March 1979, the Commission issued a Confirmatory Order on May 16, 1979 ordering Davis-Besse,                            ,
during a scheduled outage, to remain shut down until certain hardware and procedural changes and analyses were made by i
Toledo Edison and approved by the NRC staff.
NRC lifted the Order on July 6, 1979.        In its accompanying Safety Evaluation Report (SER), NRC stated:
While the Staff recognizes that the AFW system is safety grade, we also note that the licensee has agreed to continue to review the performance of the AFW system for assurance of reliability and performance. Consis-tent with this long-term agreement, we will require that the licensee modify the plant to provide the greater degree of diversity offered by a 100 percent-capability motor-operated AFW pump, or an alternative acceptable to the Staff.
On June 8, 1979, the NRC staff visited Davis-Besse to discuss Toledo Edison's efforts to respond to the Commis-sion's Order.      A week later, Toledo Edison transmitted to NRC an analysis of a complete loss of feedwater transient.
Eight days later, in response to staff questions, a Toledo
                                , Edison analysis concluded that secondary steam pressure, after less of main feedwater to the steam generators, would support the AFWS steam turbine operation if started within 20 minutes.
In April 1980, NRC issued " Transient Response of Babcock &                          -
Wilcox-designed Reactors" (NUREG-0667), which made recommen-dations for reducing the likelihood or consequences of severe accidents. One recommendation was to upgrade the                              .
,                                AFWS to include diverse power sources with either three trains, or two trains plus feed and bleed capability.
Installation of a-diverse-drive AFW pump was recommended for Davis-Besse specifically, partly because the relatively low head, high pressure injection pumps prevented injection at
;                                normal operating pressure.
In May 1980, NRC issued the TMI Action Plan (NUREG-0660),
;                              which called for licensees with B&W plants to evaluate their 14
 
l 4
AFWSs by September 1, 1980.                The staff Reactor Transient Task Force recommended that installation of a diverse-drive AFW pump be expedited at Davis-Besse.                        In August 1980, the Director Director,ofOffice      NRC'sof Division NuclearofReactor Safety Technology Regulation (wrote        to the NRR), that the recommendation of the Reactor Transient Task Force "be implemented as soon as possible by an NRC order...." This requirement, he noted, was identified in the post-TMI-2 startup authorization.                As reported above, the July 1979                          ;
,      .            authorization lifting the shutdown permitted Toledo Edison to propose an alternative. Nevertheless, the Director, Division of Safety Technology, concluded, "It is our under-standing that the licensee [ Toledo Edison] is still review-ing possible options.... This is too long a time to merely study such an important issue."
In November 1980, the staff issued "Ciorification of TMI i                    Action Plan" (NUREG-0737), which, in part, e.,nhasized that previously required analyses should include multiple events, such as the failure of both main and auxiliary feedwater systems.              These analyses were to be submitted to the staff by January 1,1981, and reviewed by July 1, 1981 (i.e., 2 years after the staff originally notified Toledo Edison that a motor-operated pump, or an acceptable alternative, would be required).
i On January 23, 1981, Toledo Edison objected, because of cost, to the NRC alternative for a diverse-drive AFW pump with a 100-percent capacity and proposed an alternate resolution, concluding:
To bring this issue to final resolution, it is proposed that, prior to proceeding on any major plant modifica-tion, a risk reduction comparison be completed to provide an evaluation of the acceptable alternatives.
This would allow us to optimize the plant response results, minimize the perturbation and still verify that the design provides an appropriate level of protection to the public health and safety now and after any such modification is complete.
In a March 5, 1981 meeting, Toledo Edison advised the staff that its August 1980 feasibility study demonstrated that
        .            providing an additional 100-percent capacity AFW pump was prohibitively expensive and required an excessive prepara-tion time.              This conclusion was based on the need to provide a completely diverse safety-grade AFW train, i.e., that entailed seismic-resistant components in a new seis-mic-resistant building, rather than just a motor-driven pump.      This change, involving a safety-grade system, appears to be what the staff had in mind.                        Toledo Edison planned to 4
perform a detailed probabilistic risk assessment to evaluate j                    acceptable alternatives.
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  ~-... - - - - _ ,,        .--                    -          .-    . _ -          - _ .  . . __              __ -_-
 
In responding on April 2, 1981, the staff recommended six ways to_ improve the reliability of the AFWS at Davis-Besse.
In commenting on the licensee's proposal, the staff noted,
  "[t]he principal thrust of [ Toledo Edison's] proposed reliability analysis would therefore try to demonstrate the acceptability of the reliability of the present two train AFWS at the Davis-Besse 1 plant." NRC rejected this ap-proach and, apparently changing its position (from the requirement for a fully safety grade, seismically qualified system), stated:                              "We believe that you should consider                                -
placing more emphasis on upgrading the existing startup feedwater train to provide diversity from the present steam driven AFWS, and thus improve system reliability." The                                                              .
sixth NRC recommendation was for installation of a di-verse-drive auxiliary feedwater pump.                              The April 2 letter stated:
We are concerned with the dependency of both AFWS pumps on steam from the main steam lines.                                      Other PWRs are known to have a similar configuration (e.g., Calvert Cliffs); however, because of the more rapid dry-out of the steam system in B&W plants, such a steam dependency is of more concern in Davis-Besse. The licensee should state plans for providing a third AFWS train which will utilize a pump powered from a source other than steam.
A schedule of implementation should be provided.
On May 22, 1981, Toledo Edison responded, indicating its intent to submit a probabilistic risk assessment on the AFWS by July 1981, which would identify dominant failure contrib-utors. Toledo Edison stated its intent to upgrade the existing startup and auxiliary feedwater systems based on results of the risk assessment.
Independently of this decision, on June 22, 1981, B&W issued "Draf t Engineering Summary Report of a Complete Loss of FW Transient Analysis for Davis-Besse" (B&W 582-7151-14-00),
which concludes that operator action (feed and bleed) within 30 minutes of a loss of feedwater will prevent the core from becoming uncovered.                                                                                                  ,
In a June 29, 1981 memorandum to NRR, the NRC Division of Safety Technology recommended adoption of a reliability criterfonintgeStandardReviewPlan (SRP) of a probability
* of 10-    to 10- for failure upon demand of the AFWS. This recommendation was endorsed by the NRC Division of Systems Integration on July 31, 1981.
The SRP, " Auxiliary Feedwater System (PWR)," Rev. 2, issued in July 1981, stated that the NRC reviewer is to determine that:
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        ... 2.        The system is protected against the effects of pipe whip and jet impingement that may result from high or moderate energy piping breaks or cracks.    -
        ... 5.        The system possesses diversity in motor power sources such that system performance require-ments may be met with either of the assigned power sources, e.g., a system with an AC
.                        subsystem and a redundant steam /DC subsystem.
The reviewer is to determine whether licensees have submit-ted sufficient information for NRC to co hasanunreliabilityintherangeof10-gcludetgattheAFWS  to 10- per demand. The numerical criteria in this review did not          apply to previously licensed operating plants, such as Da-vis-Besse.
On July 16, 1981, NRC asked Toledo Edison to provide addi-tional information on AFWS automatic initiation and flow indication.          This was submitted on September 16, 1981.      On December 31, 1981 Toledo Edison transmitted to NRC the
  " Davis-Besse AFWS Reliability Analysis, Final Report." NRC later sent the report to the Brookhaven National Laboratory for review.          (This report is discussed in Section 4.)
An NRC memorandum of March 1, 1983 repeated the recommenda-tion that NRC should require installation of a third, qualified, motor-driven AFW pump at Davis-Besse.            On Au-gust 22, 1983, the staff issued a draft proposal intended for review b ments (CRGR)y the .
NRC Committee It contained      to Review a proposed      Generic Generic      Require-Letter  to licensees concerning ten pressurized water reactors (PWRs),
including Davis-Besse, that had not made the "necessary system modifications...to ensure that their AFW systems are capable of being operated in the high reliability range. . .."
The proposal concluded that AFWS failure is a dominant contributor to core melt accidents and recommended requiring modifications to demonstrate adequate rel'iability in accor-dancewitgthecugrentSRP(Section10.4.9)failurecriteri-on of 10- to 10- per demand. The proposal included the recommendation that NRC issue a Generic Letter: it would require licensees to confirm within 30 days that changes
. would be made to the AFWS and that a design would be pro-posed within 120 days. .The analysis notes that improvements could be evaluated under the long-term Unresolved Safety Issue (USI) of decay heat removal (A-45), but rejects this 17
 
approachbecausestugyofthisissuewasnotexpectedtobe complete until 1985.
An NRC handwritten memorandum of August 26, 1983, referring to the August 22, 1983 CRGR draft proposal states:
We need to get together ASAP [as soon as possible] on the attached CRGR package-- The [ Director of Systems Integration] is tr plants (12 total) ying with to  stick a 3rd    a number AFWS  pump. of operating    .
This action will have significant ramifications on A-45. We may come up with a more comprehensive          ,
cost-beneficial solution.
Their value-impact looks weak and will be shot down by CRGR.
An NRR memorandum of August 29, 1983 reviewed implementation of recommendations for AFWSs and found the Davis-Besse AFWS acceptable.      The recommendations were based on the Toledo Edison reliability analysis of December 1981 and generic recommendations of NUREG-0611 and NUREG-0635, which did not require a third pump.      The memorandum referred to the proposal intended for the CRGR which would require all plants to upgrade their AFWS to meet existing requirements and stated that such requirements for Davis-Besse would be the subject of future correspondence.
An NRR memorandum of September 25, 1983, containing a long list of comments and questions on the August 22, 1983 CRGR proposal, concludes that a decision should be deferred:
The proposed action, if implemented independently will have significant ramifications for the USI A-45 pro-g ra m. Accordingly, further and more detailed regulato-ry analyses should be done to provide a good basis.for deciding whether this issue should be done independent-ly or combined with A-45. Until then, it is suggested that the decision be deferred.
An attachment to the memorandum refers to a September 13, 1983 meeting among representatives of NRC divisions and branches wherein they agreed that further work should be            .
done before the proposal was forwarded to the CRGR.
2 While the NRC staff was to have completed its study of USI A-45 by 1985, the current projected completion date is 1987.
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An NRR memorandum of November 16, 1983 transmits the staff evaluation of Toledo Edison's December 31, 1981 reliability analysis from the Division of Systems Integration to the Division of Licensing.                It repeats the June 1981 conclusion oftheDivisionofSafetyTechgologytgattheSRPincludean unreliability criterion of 10-                  to 10 An NRR memorandum of December 7, 1983 notes that the staff delay in responding to the August 22, 1983 proposal " result-
        ,            ed from the need to complete other higher priority work."
The memorandum states that the requirement for a third pump was considered a low priority according to a staff 4
cost-benefit analysis. The memorandum notes that changes have been or will be made at plants other than Davis-Besse.
An NRR memorandum of January 16, 1984 provides additional information on the CRGR proposal, including estimated frequencies of a core melt (per year) attributable to loss of main feedwater.                The memorandum states that the mean probability of a core melt per year from this type of incident is 5.4 x 10"4 (or 1 chancg in 1,851). (The NRC provisional safety goal is 1 x 10- or 1 chance in 10,000, per reactor year. ) -This average estimate assumes that feed and bleed emergency cooling is not possible at Davis-Besse; i                    the risk ~of a--core melt _at Davis-Besse from loss of main 1
feedwater is 5 times greater than-the probability __of a_ core melt accident in the Commission's safety goal for chances of''~
a core melt from all types of accidents at any plant.
I                    On March 2 and 3, 1984 a stuck open safety valve resulted in i                    steam generator dryout at Davis Besse.                      An I&E memorandum of I
April 9, 1984 to NRR referring to this dryout supports the CRGR proposal to require diverse AFW pump power.
'.                  An {{letter dated|date=April 23, 1984|text=April 23, 1984 letter}} from NRR to Toledo Edison provides the staff evaluation of the utility's December 31, 1981 reliability analysis and the Brookhaven National Laboratory I                    reliability analysis (NUREG/CR-3530).                      The letter notes the opposing conclusions reached by BNL and Toledo Edison and concludes that the Davis-Besse AFWS does not comply with the
        .            current SRP reliability criterion.                    It should be noted that Toledo Edison's reliability analysis takes credit for feed and bleed operations and other modifications; BNL's analysis
        .            does not.
The NRC staff report, " Comparison of Implementation of Selected TMI Action Plan Requirements for Operating Plants l                    Designed by B&W," May 1984 (NUREG-1066), concludes that Davis-Besse had completed all required plant modifications.
However, three open Technical Specification items remained regarding the Davis-Besse AFWS.                  The report noted that staff review of these items was to be completed by June 1984 J
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(nearly 5 years af ter the staff notified Toledo Edison in July 1979 that modification to the AFWS would be required).
A Toledo Edison internal memorandum of September 7, 1984 comments on the NRC's {{letter dated|date=April 23, 1984|text=April 23, 1984 letter}} and the BNL analysis. It disagrees with a number of assumptions made by BNL and the staff, particularly their lack of credit for the feed and bleed function, and concludes that their findings are " inaccurate, unjustified and irrelevant."
At an NRC-Toledo Edison meeting on September 19, 1984, Toledo Edison committed to install a relocated, electric motor-driven startup feedwater pump with full capacity at    '
the next refueling outage. Relocation was necessary to avoid a high or moderate ener                          (See License Amendment 83, above.)gy pipe break problem.
A September 28, 1984 memorandum from the Director, NRR, to the ED0 reported that the Auxiliary Systems Branch deter-mined that a diverse-drive AFW system was unnecessary.
Toledo Edison formally notified NRC in writing in October 1984 of the unanalyzed pipe break problem involving the existing startup feedwater pump.
Toledo Edison applied on November 12, 1984 for a license amendment to install the new 100-percent capacity auxiliary feedwater, electric motor-driven-startup pump at a new.
location at the next refueling outage (spring of 1986). The license amendment was approved on January 8, 1985. However, NRC required that special precautions be taken with the existing startup pump, including isolating it from the feedwater system and disabling the motor drive until the new pump was installed. The isolated startup pump, to be activated, required repositioning of four valves and the installation of fuses in the motor control system. An operator also needed to be stationed at the pump to monitor i its operation. These actions were, in fact, performed during the June 9, 1985 incident. Toledo Edison believed that isolating the startup pump actually increased risk.
On June 20, 1985, the CRGR noted in a memorandum that the regulatory proposal for improving the reliability of AFWSs still had not been submitted to the CRGR.                    .
Following the incident, NRC requested, on October 30, 1985, that Toledo Edison perform probabilistic analyses of the AFWS as it existed on June 9, 1985, and as it would exist at restart, using the assumptions and methodology of NUREG-0611.
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Advisory Committee on Reactor Safeguards (ACRS) Review Since 1979, the ACRS expressed concern about the functional capability and reliability of decay heat removal systems in general and AFWSs in particular. Although it did not specifically address B&W or Davis-Besse AFWSs in its advice
      '            to the Commission, the ACRS consistently recommended giving high priority to generic and specific upgrading of these systems. In April 1980 the ACRS observed that staff action plans in this area appeared to lack coordination in evaluat-ing shutdown heat removal requirements comprehensively. In May 1981 the Committee again recommended that high priority be given to USI A-45.    (Its resolution seems to have been inhibited by extended consideration of the need for pilot operated relief valves (PORVs) in Combustion Engineering's System 80 design.)    More than 3 years later, in August 1984, the ACRS pointed to the importance of A-45 to plant safety.
Recognizing the great variety and complexity of decay heat removal systems among the many different nuclear plants, the ACRS suggested that if a generic treatment was not feasible, timely-alternatives should be developed.
Conclusions Extensive and detailed regulatory interactions and activi-ties took place concerning the AFWS at Davis-Besse between NRC and Toledo Edison from the licensing of the plant in 1977-through-the~ June ~9~ 1985 incident.
The AFWS and related controls experienced recurring problems involving components and required a number of design changes such as the addition of dynamic brakes on the pump turbine governors and flow indication in the control room for both steam generator AFW inlet lines. Toledo Edison made appro-priate changes, including installation of a diverse power supply to one of the AFWS trains (for the motor-operated valves), that were required before the second fuel cycle.
The staff approved a license for Davis-Besse, even though it lacked diverse power to the AFWS pumps, a condition un-changed up to the incident.
[        .
i NRC's post TMI-2 evaluations of the Davis-Besse AFWS identi-l                  fied the need for short-term and long-term modifications.
However, NRC did not require installation of a 100-percent capacity, motor-driven startup feedwater pump until Toledo Edison committed to its installation in September 1984.
HRC did not believe that the Davis-Besse AFWS, as it existed before the incident, was sufficiently reliable.        This conclusion was based largely on the lack of diverse power to the pumps and the lack of full capacity of the existing startup pump. Earlier requirements for suitable 21 l                                                                                                  '
l
 
modifications of the AFWS might have been justified techni-cally, even though not required by the Commission's rules.
Both the ACRS and the staff may have contributed to an unreasonable delay in resolving the specific weakness in the Davis-Besse AFWS by focusing on a generic solution to the decay heat removal question. This finding does not suggest that generic solutions are not desirable where feasible.
Analysts should exercise caution, however, in seeking solutions to generic problems when they unduly delay spe_if-          -
ic solutions at individual plants.
Recommendations                                                        .
Regional Administrators should meet with NRC Headquarters management to review the performance of each nuclear plant and licensee in their region at least quarterly, or more frequently as needed. The Group strongly endorses the current plans of the ED0 to implement such a program. The ED0 should make prompt decisions to resolve problems and to establish appropriate schedules for completing their resolu '
tion.
Project Managers (with appropriate technical support) should visit nuclear power plants on a periodic basis (perhaps quarterly) to communicate directly with plant management and utility licensing officers.
The ED0's current development and implementation of the integrated tracking and management system to assure effec-tive continued management monitoring and resolution of safety and licensing issues are strongly endorsed.              Such a system might have been of assistance prior to the 1985 incident at Davis-Besse.
The staff should decide and communicate the results of decisions promptly to relevant staff and licensees on whether an issue is plant-specific or generic. Such deci-sions should be made or endorsed by the ED0 and action plans should be promulgated and executed expeditiously.
e 22
 
4      DAVIS-BESSE RELIABILITY ASSESSMENTS This section summarizes (a) staff requirements for the prob-
  . abilistic assessments of Davis-Besse plant safety systems, (b) the auxiliary feedwater system (AFWS) probabilistic reliability analyses performed by Toledo Edison and Brook-haven National Laboratory (BNL , (c) the staff's evaluation and use of these analyses, (d))the Davis-Besse response to the staff's evaluation, (e) S evaluation of these analyses,gndia National Laboratories'(f) a Davis-Besse post-reliability analysis, and (g) additional qualitative reli-ability techniques which might ensure greater confidence in nuclear power plant performance.
Pre-event AFWS Probabilistic Reliability Assessments AFWS reliability analyses were conducted prior to the June 9, 1985 incident by Babcock & Wilcox (B&W), Toledo Edison, and Brookhaven National Laboratory (BNL).
On December 1979, B&W completed its " Auxiliary Feedwater Systems Reliability Analysis - A Generic Report For Plants With Babcock & Wilcox Reactors."      The objectives were:
(1)  To identify, through reliability-based insights, dominant contributors to AFWS unreliability.
(2)  To assess the relative reliability of B&W operat-s ing plant auxiliary feedwater systems.
The study identified dominant contributors to AFWS unavail-ability for each plant so that B&W utilities could make ap-propriate design changes to improve AFWS reliability. For Davis-Besse, the dominant contributor noted was simultaneous
  . loss of both trains. This condition could occur if one train were out of service for maintenance during normal plant operations, and a random failure occurred in the other
  . train. The study calculated system reliability at 5, 15, and 30 minutes af ter loss of main feedwater to allow for a range of operator actions following initiating conditions.
3 J.W. Hickman and B. Ateft, " Review of Documents Related to the Davis-Besse Auxiliary Feedwater System Reliability Assessments," April 21, 1986.
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i The probability of failure to function upon demand ranged from approximately 5 x 10-3 to 8 x 10-3 The study cautions  .
that these values should be viewed as relative rather than
;    absolute values.
Toledo Edison AFWS Reliability Analysis (EDS Nuclear, Inc.)
On December 31, 1981, Toledo. Edison submitted to NRC a de-tailed probabilistic reliability analysis of the AFWS pre-pared by EDS Nuclear, Inc. (now Impell Corp.). The study                                              -
analyzed four configurations, including one for a third AFW train to upgrade the existing feedwater startup pump as a i  diverse full-capacity electrically driven pump.                                    The analy-          .
sis concluded that the most cost-effective approach was to rely on a modified feed and bleed mode using the existing startup pump, the makeup pumps and the pilot operated relief valve (PORV) to provide adequate core cooling. The study recommended upgrading other components and procedures, such as the auxiliary feedwater pump turbine governor and improv-ing Limitorque valve operations, turbine feed from both steam generators, and valve positioning. This "analy-sis-based" approach demand of 3.3 x 10-5,predicted a figurean  which          AFWS    unavailability includes  credit per      for (proper) operator actions.
Brookhaven Review of EDS Analysis In 1983, NRC directed Brookhaven National Laboratory (BNL) j  to perform an independent reliability analysis of the Davis-Besse AFWS using methodology and data from " Generic Evaluation._of_ Feedwater Transients and Small Break Loss-of-Coolant Accidents in Westinghouse Designed Operating Plants" (NUREG-0611). BNL indicated that an independent reliability analysis was requested because each applicant for an operating license was required to comply with the Standard Review Plan (SRP), Section 10.4.9.                        This section requires the use of criteria which enable direct compari witg the acceptable AFWS unreliability range of from 10 gonto 10-    per demand.      NRC wanted to compare the results for Davis-Besse with results from other plants, even though the
;  SRP criteria did not apply to Davis-Besse.                                                              '
i The BNL results assumed no time for any intervention, in-i  cluding operator actions, to recover from malfunctions or                                              -
:  maintenance errors.        The report noted that Toledo Edison                                            '
!  used a function-success criterion different from that
;  considered in NUREG-0611 (which defined unavailability as                                            ,
,  the probability per demand that the system will fail to perform its function).
i The BNL review noted that the EDS Davis-Besse study consid-ered the measure of AFWS success to be the maintenance of adequate core cooling to prevent fuel damage. BNL also 24
 
noted that " Toledo Edison assumed it was considered suffi-cient either to (1) provide flow from one AFW pump within ten minutes, or (2) establish feed-and-bleed within 30 min-utes, in conjunction with feedwater flow from the start-up pump, which is not adequate in itself to remove decay heat."
The report called attention to (a) the Davis-Besse AFWS's lack of diversity and its vulnerability to common cause failures, and (b) the Davis-Besse history of such items as
  , AFW pump speed failure, loss of control of both AFW pumps from mechanical binding in one pump and blown fuses in the other, and the loss of an essential bus.
Toledo Edison AFWS Reliability Analysis (Impell Corp.)
On November 1, 1985, the Impell Corporation submitted its study to compare its analysis with NRC staff analyses of other plants. It addressed the quantitative criteria for AFWS unreliability using data and methodology prescribed in NUREG-0611. The study, initiated prior to the June 9, 1985 incident, analyzed three AFWS configurations: (1) the exist-ing Davis-Besse AFWS configuration as of June 9, 1985, (2) a two-pump configuration, and (3) a three-pump configuration.
The configuration as of June 9, l ty on demand ranging from 4 x 10 j85          to showed  an gnavailabili-1.6 x 10-  for speci-fied initiating events using the criteria in NUREG-0611.
The three-pump system with a diverse electric motor-driven feedwater requirement pump  wasto of 10-4  predictgd 10- pertodemand.
meet the SRP unreliability Ad Hoc Group Review of Davis-Besse Reliability Analyses
_  The Group requested Sandia National Laboratories to examine the var.ious probabilistic assessments of safety system reliability at-Davis-Besse.            The objectives of the study were to review and summarize all-reliability-related studies and reports, comment on the quality and relevance of these studies to the Davis-Besse event, and reach conclusions and submit recommendations about the use of probabilistic analyses in regulatory decisionmaking. Table 4.1 from              the Sandia study shows a comparison of the results of the BNL study and the EDS Nuclear and Impell studies.
  ~
The Sandia report includes (1) a summary of the correspon-dence and activities involving probabilistic analysis of the Davis-Besse plant; (2) a comparison of the results of the utility-sponsored AFWS reliability analyses with the NRC-BNL review of these studies; (3) a discussion of the use of state-of-the-art methodology, compliance of the utility's results with the requirement of the SRP, and a discussion of the Davis-Besse plant configuration on June 9,1985; and (4) conclusions and recommendations.
25
 
i r
                                        )
                                      )
                                    /                Table 4.1 Comparison of the Results of
                                  !                            the Davis-Besse AFWS Studies a l
EDS Study                                                  Impell Study BNL Studyc ,d
                            '              (December 1981)b                                          (November 1985)d,e Configuration                          (Feb. 1984)            Configuration
                          !                                                                  Existing Planned Two Planned Three Initiator        Pre-TMI Post-TMI Third Train Analysis-Based                            (6/9/85) Pump System Pump System LossofMa}n Feedwater        3.3E-2          6.6E-4          4.5E-5        3.3E-5        1.6E-3    1.6E-3      6.6E-4      9.1E-5 Loss of Off-Site Power      4.1E-2          5.5E-3          1.4E-4        9.3E-5        2.8E-3    2.9E-3      1.7E-3      1.1E-3 Loss of All ac                                                                  3.4E-2    4.0E-2      3.3E-2      3.3E-2 Et Seismic Event      8.8E-2          1.9E-2          1.9E-2        1.1E-2 a    E-2=10-2 r
b AFWS success criteria in this study consist of a) providing flow from one AFW pump to one steam generator within 10' minutes, or b) establishing feed and bleed procedure within 30 minutes including some heat removal via the main feedwater startup pump.
c    AFWS success criteria in this study consist of successful flow from at least one AFW pump to at least one steam generator without delay.
d    Calculations based on NUREG-0611 methods and data.
e    The success criteria in this study consist of availability of sufficient auxiliary feedwater flow to at least/one steam generator within 5 minutes following the loss of main feedwater or offsite power or all ac. I f    SRP fequires an unreliability in the range of 10~4 to 10-5 per demand.
              /
            /
          /
 
7 The Group examined the Sandia study and agrees with its conclusions and recommendations.
Sandia
 
== Conclusions:==
4
: 1. Each of the AFWS reliability analyses provided sound recommendations addressing areas of system vulnerability, which found their way into the Davis-Besse design and resulted in AFWS reliabili-
  ,              ty improvements.                    ,
: 2. Each of these studies fell short of realizing the full potential of the PRA type of analysis because important support systems, such as ICS [ integrated control system] and SFRCs [ steam and feedwater rupture control system], were not modeled.
: 3. State-of-the-art limitations with respect.to modeling of heroic recovery actions and human errors of commission, such as the one that oc-curred during the Davis-Besse 1985 incident when 4                the operator inadvertently pushed the " low pres-sure" buttons, prevent PRAs from covering all aspects of events such as the Davis-Besse inci-dent.
: 4. The reliability analyses performed as a part of NUREG-0611 and NUREG-0635 had limited scope and were not originally intended to be used as a guide for SRP purposes. This limited scope does not cover all unusual occurrences which happened in
'                the Davis-Besse event such as those which were due to the initiation system.
: 5. Overall quality of the reliability analyses reviewed with respect to the use of state-of-the-art methodology and date was satis-factory.
Sandia Recommendations:
: 1. The recommendations of SRP Section 10.4.9 with respect to following a set of guidelines on
  ,              methodology and use of data for AFWS reliability evaluation should be updated to include a much more comprehensive set of guidelines.      Consider-4 Sandia conclusions and recommendations are quoted verbatim, except for bracketed statements added by the Group for clarity.
N x
x                                27 x
                      'N_. __
Nm
                                          "~.
                                          , --    DN                  - -
 
ation should be given to more detailed modeling of human actions, and [ support systems such as]
power, control, initiation, and cooling systems rather than treating the auxiliary feedwater system in isolation from its support systems.
: 2. The current SRP unreliability requirement is not clearly defined and applies only to the loss-of-main-feedwater-system initiator. Unreli-ability requirements for other initiators such as                              .
loss of offsite power and total loss of ac (stg-tion blackout), should be considered.                                The 10 requirement of the SRP does not appear to be                                  ,
appropriate for station blackout events.
: 3. Review of PRA documents by the NRC should not be limited to the compliance of the submitted report with a set of narrow guidance such as SRP.                                NRC reviewers should be encouraged to provide addi-tional comments and insights about the areas of system vulnerability beyond the pure compliance guidance.
Use of Reliability Probabilistic Analysis in Regulatory Decisionmaking The previous sections illustrate the differing views about how probabilistic analyses are conducted, both from the standpoint of the approach to the analysis, and in the numerical values used and generated by them.
Key NRC management personnel interviewed by the Ad Hoc Group believe there is considerable value in the use of fault trees in reliability analyses, and that this discipline alone may call attention to potential problems if properly applied by licensees and the NRC staff.                                  They also believe that numerical values from probabilistic analyses should be viewed as a goal toward which to aim rather than as a quantifiable value by which to neasure what a given plant has actually achieved.      A licensee can conduct plant-specific probabilistic analyses with a valid data base                                -
which can be useful in detecting design weaknesses and undesirable trends in plant performance.
Additional Qualitative Reliability Techniques for Regulatory Decisionmaking During interviews with NRC management, the Ad Hoc Group discussed the use of other reliability and management techniques, including (1) configuration management controls, (2) failure modes and effects analysis, (3) component qualification control, (4) rigorous failure reporting and corrective action systems, (5) maintainability analyses, and 28
 
(6) improved maintenance.                Although most of those inter-viewed agree these techniques would be useful to licensees in improving availability and in enhancing safety, they believe it would be difficult to prepare detailed regula-tions to require that these disciplines be implemented by licensees.
The Director of NRC's Office of Inspection and Enforcement (I&E) has conducted several safety system functional inspec-
      ,                  tions and outage system modification inspections that revealed plant desiga and safety issues.                      These findings reinforca the value of addressing reliability and management techniques in preventing incidents that threaten plant safety.
A recent publication by the NRC Division of Waste Management (NUREG/CR-4271) recommended that the safety, reliability, quality assurance and management techniques used in the aerospace industry could possibly be applied by the Depart-ment of Energy for the High-Level Nuclear Waste Repository Program. The document describes successful aerospace management, safety, reliability assurance and quality assurance techniques, as well as specific aspects of the case of technology transfer, which may also be applicable to nuclear reactor operation and regulation.
Conclusions The conflicting assumptions, methodologies and findings in licensee and NRC staff reliability analyses, and considera-tion of the CRGR memorandum on PWR AFWs, were factors in delaying the final decision on the installation of a diverse electric motor-powered auxiliary feedwater pump.                      Another factor delaying a final decision was the staff's delay in generic resolution of the decay heat removal issue, Unre-i solved Safety Issue (USI) A-45.
Improvements in probabilistic analyses of safety systems can be achieved by inclusion of important associated systems and a more defensible plant-specific data base.
Additional qualitative reliability techniques and measures over and above probabilistic analyses could be useful to
    '                  increase confidence in the safety of nuclear power plant operation.      Improvements in the probabilistic analysis process will be more useful in NRC regulatory decisionmaking if they are augmented by information gained from other qualitative management and reliability techniques, such as configuration management, failure modes and effects analy-sis, and other disciplines referred to in this section.
i l
29 l
l
_ - _ . , _ _ .              _      . _ _ _ _ . _ _ - -      , _ _ - - . _ _              _ ____._i
                                                                                                                - . _ _ _ _ -L
 
i Recommendations NRC should establish a timely and effective process to review reliability analyses requested of licensees, particu-larly where it is determined that such analyses will be used in regulatory decisionmaking.
NRC should evaluate the use of qualitative management and reliability disciplines as a means of increasing confidence in the day-to-day performance of nuclear power plant                          -
licensees.
I&E should give priority to the conduct and promotion of                      .
safety system functional inspections and outage system modification inspections.
1 e*
                          ,e
                ,,P
        .-                                                                30
 
c                ?
r b'                          %  )
{          s
                                                                                )
1 5    CONTRIBUTION OF TOLEDG EDISON'S. MANAGEMENT,-OPERATION, AND: MAINTENANCE PROGRAMS TO EQUIPMENT FAILUR,ES
  .        TheToledoEdisonNuclearProgra.{                  ,
The Ad Hoc Group examined the st'ructure and' staffing of
  ~
Toledo Edison's Nuclear organization to determine its effectiveness prior to June 9, 1985. During 1979,.the Davis-Besse Plant Superintendent reported to the company Vice President for Energy. Supply.      A separate organization for nuclea'r operations was established in 1980 with a Vice President for Nuclear, and several reorganizations were '
implemented between 1982 and 1985 tc' strengthen Toledo Edison's Nuclear mission.
Between 1979 and 1985, the staff of the> Nuclear mission increased from 340 to 590 employees to remedy deficiencies and to improve performance.      A Performance Enhancement Program (PEP), initiated in November 1983, required the extended services of over 100 persons. 'The program, costing approximately $18.9 million, covered 16 areas, i ncluding maintenance, training, safety managemerit, fire protection, security, and configuration management.
                                      ~
In 1983 Toledo Edison also formed a corporate Steering Group,' headed by the Vice President for Nu, clear, that reported to the President.
Performance Teams were organized to review issues of signif-icant safety or regulatory importance a'nd their assessments identified whether probldms were understood'and whether reasonable interim actions were defined. Changes to interim action plans in the PEP program had.to be approved by the plant manager and.a Steering Group.. The PEP program was reviewed by Region III in the light of improvements request-ed by NRC and other changes decided upon by Toledo Edison; one' noteworthy example was a computerized maintenance man.agement system.
A Senior Vice Presid~e.nt'for Nuclear, hired in July 1985,
          > made a nus.ber'of changes in the organization, among which were:    (1) a preference for in-house rather than consultant expertise to assure tecti nical continuity, and (2) consolida-tion at 'the ' Davis-Besse ' site of engineering and other support functions previously divided between the plant site and corporate headquarters.
31
                      +        . . . . .
 
The Technical Specifications for Davis-Besse require the establishment of review groups to consider and recommend facility changes and review plant operational data. Among other responsibilities, the Davis-Besse Station Review Group examines all safety-related transients and incidents at the plant and reviews and recommends approval for plant safe-ty-related operating procedures.
A Company Nuclear Review Board (CNRB) subsequently reviewed the decisions and recommendations of the Station Review        -
Group. The CNRB initially drew upon personnel from Toledo Edison Nuclear and other company personnel and-later added several outside experts. It met approximately 18 times per  .
year and relied upon analyses performed by other groups in the corporate structure. The CNRB is responsible for reviews and audits of the plant's operations and procedures
, and for advising management in the areas reviewed.      It also reviews issues resulting from regulatory actions (e.g., SALP reports, emergency planning changes, plant modifications and changes to Technical Specifications).
The Davis-Besse Maintenance Program The Davis-Besse maintenance program staff grew substan-tially--from a complement of 34 to 207--between 1977 and the 1985 incident. According to Davis-Besse management, the increase was in response to surveillance requirements of the Technical Specifications as well as the requirements result-ing from TMI and other regulatory issues.
At the time of the June 9, 1985 incident, Davis-Besse had 1339 open corrective work orders, 111 open facility change requests, and a preventive maintenance backlog of 405 work orders. There is evidence that prior to the event, a large backlog of equipment needing maintenance existed, some of which was undoubtedly due to deferring certain maintenance tasks until an outage period.      The prevailing pre-event maintenance practice, particularly for the balance of the plant, appeared to be directed toward maintaining only that equipmer.t essential for safe plant operation.
Operating nuclear utility experience demonstrates that many challenges to emergency safety systems arise from malfunc-tions in balance of plant equipment.      Accordingly, a large  -
backlog of maintenance items appears to have safety signiff-cance, even though related generally to non-safety grade          !
systems and components. NRC periodic Systematic Assessment        '
of Licensee Performance (SALP) reports II, III, and IV indicated that improvement was required in Davis-Besse's maintenance program.
SALP assessments are performed over a period of a year or longer by teams led by Regional personnel. The purpose of 1
32 l
 
these reviews is to collect recorded observations on a periodic basis and evaluate licensee performance based on                    1
,            those observations.          The assessments consider positive and            i negative attributes of licensee performance and emphasize an                  i understanding of the reasons for a licensee's performance.                    !
The SALP process and ratings focus on assuring that the                      l resources of both the NRC and the licensee are allocated to functional areas needing improvement.          SALP ratings are              ;
classified in three categories:
: 1. I&E inspection efforts can be reduced.
: 2. Inspections should continue at the same level.
: 3. Additional effort by the licensee and I&E is necessary to improve licensee performance.
Although 3 is the most unfavorable category, it constitutes acceptable reactor safety performance. SALP IV (1984) reported that maintenance personnel errors accounted for the submission to NRC of 8 of 13 Licensee Event Reports (LERs) and that 5 reactor trips (unscheduled plant shutdowns) were I
traceable to maintenance activities. Several equipment malfunctions resulted from inadequate corrections of previ-ous equipment failures, including a containment building i
isolation valve and the safety features actuation system radiation meter. NRC's SALP IV assessment of Davis-Besse's maintenance reorganization was that "an appreciable improve-ment in field performance was not observed."          Region III personnel submitted no information that the resources and organization for the Davis-Besse maintenance program were markedly different from organizations at other plants.
Since the incident, the Davis-Besse maintenance program has
;            been substantially reorganized and a new maintenance manager
!            has been appointed.          A major maintenance facility planned j            prior to the incident is now under construction.
INP0 has prepared guidelines for a "high level of perfor-
      '      mance" maintenance program covering items such as mainte-nance department organizations and administration; training and qualification of maintenance personnel, and          maintenance facilities, equipment, and tools. " Guidelines for the Conduct of Maintenance at Nuclear Power Stations" (INPO-85-038). Davis-Besse plans to obtain INP0 accredita-tion by the end of 1986 or earlier for the plant's mainte-nance training program.
The Davis-Besse Quality Assurance Program i            The four SALP reports on Davis-Besse call attention to
,            several quality assurance (QA) problems which were taken by 33
 
SALP evaluators to indicate a lack of upper management direction and involvement in the QA program.
Toledo Edison hired an outside organization (CER Corpora'-
tion) to independently assess the Davis-Besse QA program in October 1984. The study was completed after June 9, 1985.
It identifies a number of quality control issues, such as centralizing document control, expanding the role of quality engineering beyond procurement, and coordinating work with NRC to improve SALP ratings.      All issues identified in the ,
report are currently under review by the NRC staff.
Davis-Besse Plant and Safety Performance                      ,
The Ad Hoc Group reviewed several information sources bearing on Davis-Besse plant and safety performance.      In addition to NRC SALP reports, a Region III Davis-Besse Study Group report written after the June 9, 1985 event, was also considered.
SALP results for Davis-Besse are summarized in Table 5.1.
It shows that of the 11 functional areas reviewed in SALP IV, five were rated as Category 3 and three of these five were declining in performance.      Four of the remaining six functional areas were rated as 2, and two of those were improving.
SALP reports on plant operations, surveillance and testing, and licensing activities were consistently rated as adequate (i.e., as category 2) while refueling operations rated as category 1. SALP I report (December 31, 1980) noted that a large number of " serious regul6 tory concerns existed with
! the Davis-Besse operation" and that Davis-Besse operating performance was " clearly below average" compared with other Region III licensees. In commenting on the SALP II report, the NRC Regional Administrator concluded that overall regulatory performance at Davis-Besse had shown considerable improvement. However, in his letter on SALP IV (1984), he commented that a noticeable positive impact was not evident during the appraisal period and that performance had declined.                                                  -
Subsequent to the 1985 incident, Region III established a study group that broadly reviewed the history of Davis-Besse  .
between March 1979 and June 1985.      It conducted its review using LER and inspection history, status of TMI items, and a review of management and enforcement meetings. (Attach-ment F of the Study Group Report, with violations catego-rized by SALP functional areas, is reproduced as Table 5.2.)
The Group's report also showed that after TMI through 1983, Davis-Besse submitted 391 Licensee Event Reports (LERs) to NRC.
34
 
Table 5.1 SALP Ratings at Davis-Besse*
Period of Review **
Functional Area                              I    II    III  IV
    ,    1. Management Control                    2
: 2. Plant Operations                      2      2    2    2
: 3. Refueling Operations                  2      1    1    1
: 4. Maintenance                          2      3    }+ +3
: 5. Surveillance and Pre-op. Test.        2      2    2+ +2
: 6. Training                              2                }+
: 7. Radiation Protection                  2      1    1    1
: 8. Environmental Protection              2      2
: 9. Emergency Planning                    3      1    2+  3+
: 10. Fire Protection                      2      2    2  +3
: 11. Security and Safeguards                  3      2  +2    2
: 12. Design Changes and Modificctions        2
: 13. Reporting                                2
: 14. QA Audits                                2      3          3+
: 15. Communications Activities                2
: 16. Quality Control                          2
: 17. Procurement                          2
    ,    18. Licensing Activities                            2    2+ +2
* Blanks indicate factors not rated; arrows indicate whether performance is improving (left) or declining (right).
          ** Period of Review:      I November 1,1979 to October 31, 1980 II November 1, 1980 to March 31, 1982 III April 1, 1982 to March 31, 1983 IV April 1,1983 to August 31, 1984 35
 
Table 5.2    Summary Of Violations SALP Functional                                                -
Areas                78    79  80    81  82  83  84  85 Plant Operations      2    5    3    2    7  2    5    5  .
Radiological Controls              5    1    8    0  0    0    0    1 Maintenance            1    2    1    4  6    6    5    3 Surveillance          3    1    2    3  4    2    5    2 Fire Protection      2    4    2 a    c 1  6    9    O    0 Emergency Preparedness          0    0    0    0  0    0    2    1 Security              8    7  24    1  4    2    4    1 Refueling            0    0    0    0  0    0    0    0 Quality Programs &
Administrative Controls              8    9    1    2  4    3  16  11 Training              b    b    b    b  b    2    1    2 TOTALS              29  29    41    13  31  26  38  26 a    Fire protection violations under consideration for possible escalated enforcement action.
b  Not rated as a SALP functional area during this year.
c  Following inspection conducted in June 1984 (IR 84-10);
no violations were identified.
36
 
From data submitted by Toledo Edison, it is evident that the plant has a history of operational problems and equipment failures that resulted in a significant number of plant outages and 'an adverse impact on plant capacity factor. The average capacity factor from 1978 to 1984 was roughly 45 percent, for which annual data are shown in Table 5.3.
Table 5.3    Capacity Factor and P'lant Outages from 1978 to 1985 Capacity          Plant        Number of Year              Factor          Outage      Outages
    ,                          (%)            (Days)  ,
1978              35                188                14 1979              41                192              14 1980              27                212              19 1981              57                129              12 1982              42                177                  4 1983              64                  99              15 1984              56                136                  6 1985              26                  --              --
The Ad Hoc Group has not evaluated how SALP ratings, LERs, Technical Specifications, Operational Violations and forced outage times at Davis-Besse compare with an average nuclear power facility.
Organization for Nuclear Management It is difficult to show a causal relationship between
,      specific Toledo Edison management, operation and maintenance l  . programs and the equipment failures that caused or exacer-l      bated the June 9, 1985 incident.
l 0  As reflected in the various SALP reports and management and l
enforcement conferences, the effectiveness of management controls and corrective action programs at Davis-Besse was a general NRC concern. Toledo Edison management responded by reorganizing a number of times to gain better control of its nuclear operation. Nevertheless, the NRC Region III Admin-istrator judged the management to be weak because he said it was unable to operate consistently within Agency regula-
;      tions. He indicated further that when top utility manage-ment is a part of the problem, NRC inspectors find it more 37 l
l l
 
l difficult to delve into management issues.      Neither Region III nor NRC Headquarters personnel appear to have the requisite expertise to assess management performance.
,            The current Vice President for Nuclear, Toledo Edison, offered observations on management competence in operating nuclear organizations. First, with respect to the Board of Directors of a nuclear utility, two important skills that should be represented are extensive experience in actually managing a nuclear utility program and extensive experience          _
,            in managing the budget for a nuclear utility program.          If persons with such skills are not on the Board, experienced consultants with these skills should be obtained and should          -
report to the Board, or to a subcommittee of the Board that is responsible for the nuclear affairs of the company.
Second, with respect to staffing, personnel should be hired and trained who are capable of working in a highly regulated industry; a utility must be able to compete in the job
,            market for the highly skilled personnel necessary. It is also important for these executive skills to be represented in NRC to produce effective regulatory performance.
The General Accounting Office, in a January 1986 report rec-ommends that NRC establish criteria where significant improvements are an issue, that results in NRC being j            required to mandate improvement programs or document why l            they are not warranted. The report noted Davis-Besse as one of the 12 operating nuclear plants required to implement facility-wide improvement programs. (" Nuclear Regulation:
Oversight of Quality Assurance at Nuclear Power Plants Needs Improvement," GA0/RCED-8641.)
{            Both the industry's Institute for Nuclear Power Operations (INPO) and the NRC staff have been trying to develop perfor-mance indicators to assist in judging management perfor-mance. The Office of Inspection and Enforcement (I&E) is responsible for the coordinated plan to develop performance 4
indicators for NRC.
Regulatory Oversight
!            Neither the Atomic Energy Act nor NRC's regulations includes i            a single integrated section that addresses requirements related to licensee management performance. The only                  ,
provision of the Atomic Energy Act that may be pertinent is Sec. 103 b., which states that "the Commission shall is-sue... licenses...to persons...who are equipped to observe and who agree to observe such safety standards to protect health and to minimize danger to life or property as the Commission may by rule establish."
The Davis-Besse Nuclear Power Station is subject to the rules and regulations of the U.S. Nuclear Regulatory
]                                               38
 
i Commission (NRC) as specified in Title 10 Code of Federal Regulations, Part 50, " Domestic Licensing of Production and Utilization Facilities," and its Appendices (10 CFR 50).
The plant design must meet the General Design Criteria of 10 CFR 50 Appendix A and the quality assurance program must comply with the Quali'ty Assurance Criteria for Nuclear Power Plants in Appendix B. Plant operations must also conform with Commission rules specified in the regulations as well as the operating license, conditions of the license, and the
        .- plant's Technical Specifications.
The NRC staff review and evaluation of the Davis-Besse application for a license was guided by NRC's Standard Review Plan (SRP). The application was also reviewed by the Commission's Advisory Committee on Reactor Safeguards (ACRS). NRC's Office of Inspection and Enforcement (I&E) made periodic inspections of the facility during its con-struction and continues to inspect the plant's operations.
NRC's requirements for safe plant operation include the license conditions contained in 10 CFR 50.54. Among other conditions, licensee management is prohibited from allowing anyone who is not a licensed operator from manipulating a reactor's controls.
Regulations governing safe plant operations are also regu-lated by provisions in 10 CFR 50.36, which describes infor-mation which must be included in a licensee's Technical Specifications. The Technical Specifications include an organization chart of the corporate structure for offsite Toledo Edison facility management and technical support and administrative controls necessary for management to assure safe operation of the plant. Station staffing and plant organization are s.lso described.
The requirements for the licensee's management of quality assurance (QA), specified in Appendix B to 10 CFR Part 50, specify that QA program managers be given direct access to the appropriate levels of management to perform the QA function. Appendix B also requires QA independence from cost and schedule considerations where safety is involved.
Part 50.72 contains the notification requirements for
        . various emergency and nonemergency events which are applica-ble to licensee management; the licensee is responsible for informing NRC if a reportable event occurs at the plant.
Impact of Regulatory Oversight There are many NRC requirements, besides those discussed above, that have an impact on how management performs in operating and maintaining a nuclear plant.
39
 
i The NRC staff principally performs its oversight of licensee
;                                  rograms through the Offices of. Nuclear Reactor Regulation p(NRR) and Inspection and Enforcement (I&E). The mechanisms
                                . used include license conditions and Technical Specifica-tions, rulemaking, regulations, policy statements, Commis-j                                  sion Papers, Confirmatory Action Letters and Orders, Generic j                                  Letters, Bulletins, Circulars, TMI Action Plan letters, Regulatory Guides, the Standard Review Plan, Branch Techni-cal Positions, and Unresolved Safety Issue Resolution Reports.      Mechanisms used to interpret requirements include                                                                                              ,
approval of topical reports, Safety Evaluation Reports, the Inspection and Enforcement Manual, the Project Manager's 3
Handbook, I&E Headquarters Positions, and open issues Mechanisms used to communicate a                                  resulting from inspections.
requirements to licensees include inspector entry, exit and management meetings, staff information exchange meetings, Information Notices, phone calls and site visits, Prelimi-i nary Notifications, public meetings, workshops, resident inspector dail al Team (PAT) reports, y contacts,                      SALP reports, Commission          Papers,      Performance and others.Apprais-Enforcement actions include notices of violations and deviations, enforcement conferences, civil penalties and orders to cease and desist.and to suspend, modify or revoke
;                                  a license.
4
:                                  That this plethora of requirements has an impact on licensee performance cannot be overemphasized. Between the TMI-?
P accident in 1979 and the June 9, 1985 incident, there were 72 amendments to the Davis-Besse operating license, or approximately one per month. The Toledo Edison Corporate Nuclear Review Board Chairman indicated that the Board's
,                                  activities were driven by the Jibensee's Technical Specifi-cations so that most of its J.ime was spent on paper reviews
;                                  rather 4han on assessing plant performance.                                                    Out of nearly 3
400 items that the CNRB tracked between 1979 and 1985, i
approximately 40 related directly or indirectly to the AFWS alone.
Senior technical personnel at Davis-Besse advised that the
                    ,            complexity and multiplicity of regulatory requirements complicated effective management of the plants.                                                        The                                                      -
situation was underscored by the Assistant Plant Manager
,                                  with respect to fire protection requirements alone: " Ev e ry j                                  month it seems a different person comes in, wants you to do                                                                                                      ,
!                                something. In the meantime you are so busy spinning you*
wheels on these things, you are losing track." He also thought that, although the regulations and regulatory
!                                activity in any single area may be well-founded, the totali-l                                  ty of NRC requirements adds greatly to management burdens in operating the plant.                            It was alleged that the regulatory l                                requirements are not always consistent and two examples j                                  related to the. Davis-Besse incident were cited.                                                    First, during the incident, plant physical security barriers slowed 4                                                                                            40 i
4 re~~--v-*---+,-      , . - -      .____ ._    _ _ . _ _ . _ _- , , . _ _              .m._m_ ,_,    ,m__,.,_.,,...,_m_          _,_.o , , , . , . , . _ _ _ . . . . , - , - _ _ _ - , , _
 
I operator access to areas in the plant crucial to bringing the plant under control. Second, the NRC requirement isolating the startup f.eedwater pump. proved to be an impedi-                    '
ment in securing prompt recovery of the plant.
The Group discussed with the EDO, major office directors and Region III personnel, the potential negative impacts on safety from regulatory oversight. There was no consensus on this issue, although there was substantial agreement that
    ,          certain regulations or combinations of regulations could decrease safety and that NRC oversight could be too heavy in certain areas. The staff has been aware of this impact,
    ~
as is evident from its efforts in the TMI lessons learned task force, the current staff review of certain regulatory
:                requirements (reactor containment building leakage and licensing review of fuel design), the current review process to control rulemaking, current revisions to the CRGR char-ter, and the Manual guidance for management of plant-specific backfitting in nuclear power plants.
The Group did not want to assess whether regulatory over-sight is a problem based solely on interviews with Da-vis-Besse management and staff. To gain added perspectiv the Group interviewed executives of four other utilities.g, The Vice President of Commonwealth Edison, with 15 years in the nuclear business, stated "I am still concerned that for most of our plants the greatest problem that we have is trying to deal with all of the requirements." The Vice President of Florida Power stated, "One of the things we
,                have learned as an industry, and regulators understand this also, is you don't want to challenge your system when it's operating. Yet the standard tech specs put me into a t
position of requiring me to do tens of thousands of surveil-
:                lances during the course of the year with my reactor operat-
;                ing, to encourage it to trip."
i The Vice President of Duke Power Co. indicated that the impact of regulation had produced an unmanageable situation at some nuclear plants. Where regulatory recommendations i                are made that the utility believes have no valid basis, the
    -          recommendations need not be followed. If the utility does not have the resources to take such a position, however, the utility can become so involved in responding to the j    .          recommendations that it cannot manage the plant properly.
S The utility representatives were also questioned about the IIT process and the effectiveness of NRC oversight on poor nuclear plant management practices.
[
41
 
The Assistant General Manager, Nuclear, of the Sacramento
_              Municipal Utility District stated that "it is the intensity which the management people and the technical people have to deal with the regulatory process that really eats up...the manpower and manhours that I think would be better placed on the details of the plant...."
Finally, the Group noted the rather extensive exploration of the " Safety Impact of Regulatory Activities" conducted by senior members of the NRC staff itself in 1981 (NUREG-0839).  -
Comments of the 12 utilities surveyed for the study were strikingly similar. With few exceptions, no NRC requirement was viewed in itself as unsafe or unreasonable. The single    -
survey finding was that "notwithstanding the competence and good intentions of the staff, the pace and nature of regula-tory actions have created a potential safety problem of unknown dimensions." The problems cited are the large number of regulations and the many regulatory bodies in-volved, varying interpretations by inspection personnel, extensive growth in surveillance testing, delays in agency approvals, and the adversarial environment in which NRC reviews are sometimes conducted. Time limitations on the Group review did not permit an adequate opportunity to determine whether these problems influenced the incident at Davis-Besse.
The Commission, in its 1986 Policy and Planning Guidance to the staff, has called for a comprehensive review of NRC regulations and a reduction in the numbers and prescriptive-ness of both regulations and Technical Specifications. The Group's review supports the need for such a comprehensive review.
The Group sought suggestions from NRC, utility, and industry officials as to how the regulatory process could be im-proved, both from the standpoints of regulations which may be detrimental to safety and of more effective regulation.
The Group knows that the ED0 has strongly urged utilities to implement " integrated living schedules" for accomplishing both NRC-induced and utility-initiated changes or other        -
actions for their plants. There is some hesitancy, however, on the part of many utilities to cooperate until they can evaluate the initial experience of those complying with the    -
new schedule. The concept of an integrated, flexible schedule is generally supported, but it appears that more effort is needed both by the staff and the licensees to make it work.
The Group was disturbed by allegations that the whole process was overly adversarial, that it took place in an environment of hostility and confrontation, and that often it dealt with " picayune detail" and questions that do not 42
 
enhance plant safety but engender resentment by operators and engineers toward NRC. A criticism, presumably directed primarily at Headquarters staff, was that little reactor operation or plant management experience can lead to a lack of understanding of the difficulty of implementing staff requirements in the field. The Group understands that the Commission is taking steps to ameliorate the situation.
When the Davis-Besse AFWS was designed, it was a bal-ance-of-plant (B0P) system and was not required to be-safety-grade, although it was essentially safety grade.
Accordingly, it was not treated as safety grade by the staff in its design review.
The General Design Criteria, first published in 1971, apply to structures, systems and components "important to safety."
A 1981 memorandum from the Director of NRR states that "important to safet features, covered (y...
not encompasses    the broad class necessarily explicitly)      of plant in the General Design Criteria, that contribute in an important way to safe operation and protection of the public in all phases and aspects of facility operation (i.e., normal operation and transient control as well as accident mitigation)." It also states that the important-to-safety class includes the safety-grade class. Utilities, however, have used the two terms synonymously, relegating those items not safe-ty-related to the class "non-safety related." The Introduc-tion to the General Design Criteria points out that some of the specific design requirements for structures, systems, and components important to safety have not as yet been suitably defined. Their omission, however, does not relieve any applicant from considering these matters in the design of a specific facility and satisfying the necessary safety requirements. These matters include, for example, consider-ing redundancy and diversity requirements for fluid systems important to safety. Confusion has persisted over what design and quality assurance criteria apply to 80P items.
Conclusions
. The number of organizational changes made by Toledo Edison in its pre-event nuclear mission and programs to enhance reactor safety performance were not sufficient to prevent
. the June 9, 1985 incident; neither was NRC oversight and enforcement effective in preventing the incident.
It was not apparent that Toledo Edison's Company Nuclear Review Board (CNRB) performed its everall audit function of plant safety effectively.
There were deficiencies in the effectiveness of the manage-ment and oversight of plant operations which had been recognized in NRC's SALP evaluations.
43
 
r The Group recognizes that balance of plant items are impor-tant to safety.
The pre-event maintenance program at Davis-Besse was charac-terized by many weaknesses and deficiencies. The pre-event preventive maintenance program was not systematically developed and managed.
Compliance with the substantial, growing volume of prescrip-tive regulatory requirements may have acted to reduce rather  .
than increase plant safety.
Recommendations                                                _
The NRC should shift emphasis away from detailed, prescrip-tive requirements toward performance-based requirements. A systematic, continuing review of NRC's regulatory require-ments embodying the full scope of regulatory oversight is needed to ensure that these requirements are coherent, consistent, and act to improve plant safety. Responsibility for this function should be assigned to a specific office.
NRR management and Regional Administrators should meet with the licensee's Board of Directors when a plant's deteriorat-y                        ing performance warrants. The purpose of such      meetings would be to discuss the adequacy of the licensee's activi-ties to protect the health and safety of the public.      It would also provide the Board with an opportunity to express its views on the effectiveness of the current regulatory process.
NRC should take advantage of INP0's programs to assess licensee's maintenance management programs to the extent reasonable and practical.
The staff should improve its follow-up on licensee correc-tive actions. Licensee " integrated living schedules" should be encouraged.
Resolution of the "important to safety" issue, and its application to balance of plant (80P) items in existing, as    -
well as future plants, deserves high priority. (The Group understands that I&E has responsibility for resolution of at least part of this problem.)                                    .
44
 
;                            6        NRC INCIDENT INVESTIGATION PROGRAM Background for the Incident Investigation Program
:                            The Kemeny Commission report-of its investigation of the accident at Three Mile Island (TMI) recommended creation of
            ~
an independent safety organization to provide NRC with 2
reactor safety oversight. The Rogovin Inquir Special Inquiry Group on-the TMI-2 accident) yalso                                                      (NRC's
^
specifi-cally recommended the establishment of an independent Nuclear Safety Board.                                            As a result of a Congressional
;                            requirement in the NRC's FY 84 appropriation legislation,
:                          the NRC Office of Analysis and Evaluation of Operational Data (AEOD) requested that Brookhaven National Laboratory (BNL) evaluate the feasibility of such a Board.
On February 15, 1985, BNL, after evaluating various indepen-dent safety board options, recommended that NRC consider an independent Nuclear Safety Board or expand the scope of the Advisory Committee on Reactor Safeguards (ACRS) to provide
!                          an oversight function.                                                The ACRS supported the BNL proposal j                          for an independent safety organization.
4 Subsequently, the Commission directed the NRC staff to
;                          evaluate the BNL report. The staff recommendation appears
;                            in SECY-85-208 and was approved by the Commission in October
!                          1985. The paper recommended establishment of an Incident j                            Investigation Program (IIP).
The Group assumed SECY-85-208 to be basic Commission guid-ance for che NRC's IIP. The staff subsequently prepared draft Manual Chapter (MC 0513) on the IIP.                                                              The Group, in
,                          addition to the Davis-Besse investigation, considered the t      ,1 practices and procedures followed by the investigations for
          .                San Onofre and Rancho Seco. In assessing the IIP, the Group made no evaluation of independent safety organizations, such i
as those recommended in the BNL report.
Mandate and Instructions for Incident Investigation Teams (IITs)
[                          The need for an IIT is to be determined by the potential l                          safety significance of an event, its nature and complexity, and its potential generic implications.                                                          Events judged by I                          the staff to be of lesser safety significance are to be i
investigated either by a Regional Augmented Inspection Team or through the normal inspection process. The Executive
!                                                                                                                45 l
i
{
_ _ _ _    . - , _ . _ -    ,,_.-~.__m        , _ , _ , _ _ . - , , _ , , , . , , _ _ . _ , _ , . . _ _ _ _ _
 
Director for Operations (ED0) authorizes an IIT based on recommendations from AE0D, the Office of Inspection and Enforcement (I&E), the Office of Nuclear Reactor Regulation (NRR), the Office of Nuclear Material Safety and Safeguards (NMSS), and Regional Administrators.
The program is designed to ensure that an investigation is structured, coordinated, and formally administered in order to be prompt, thorough and systematic. An IIT is to collect and document factual information and evidence and concen-    .
trate on probable causes of an incident rather than on possible violations of NRC rules and regulations.
MC 0513 indicates that the investigation should include the relevant facts and circumstances necessary for a full understanding of the event. The investigation would also identify probable causes and assess any pre-event relation-ship or interaction between the licensee and NRC which contributed directly to the event. MC 0513 also provides guidance as to areas for investigation, to include condi-tions preceding the event, event chronology, systems re-sponse, human factors considerations, equipment performance, precursors to the event, safety significance, and radiologi-cal considerations. Areas excluded from the investigations include wrongdoing or individual responsibility, generic implications for other plants, adequacy of plant design, and the licensing basis for the facility.
The Davis-Besse IIT was given 30 days to complete its investigation, but required 44 days. The San Onofre and Rancho Seco IITs were given 45 days to accomplish their tasks and were given the additional assignment of assessing pre-event interactions between NRC and the licensees.
Capabilities of IIT Members The E00 selects Team Leaders from the Senior Executive Serv-ice who have not had significant prior involvement in the licensing or inspection of the plant involved. The Leader selects other Team members from pre-approved rosters. Fu-ture IIT members will receive investigative training before  -
assignment, to the extent practical. Members will continue to be selected on the basis of technical and operational ex-pertise, and their freedom from direct involvement in the    -
licensing or inspection of the plant involved. Representa-tives from outside NRC (e.g., INPO, nuclear steam system suppliers) can be invited to participate in incident inves-tigations. The Rancho Seco IIT included a representative from INP0 who, although involved in the Team's evaluations, was not a signatory of the Team's final report.
46
 
IIT Operational Procedures The information collection and evaluation process for the three IITs was similar. Members interviewed plant personnel and reviewed plant data for the period immediately preceding and during the event.          Failed equipment and control room in-strumentation and controls were inspected. The equipment which malfunctioned and contributed to the event was quaran-tined
-    cally.go The thatteams troubleshooting obtained photographic    could be performed    systemati-documentation    of failed or damaged equipment, a valuable technique in their investigations.
The Davis-Besse IIT made transcripts available to personnel interviewed, and permitted them to be interviewed in the presence of advisors or counsel.                    Transcripts were also made available in the subsequent incident investigations at San Onofre and Rancho Seco.
The IITs placed high priority on interviewing personnel on shift during the event.          Scheduling problems made strict adherence to this policy impossible.                    In some cases, the IIT was split into two groups to expedite the interviews.
During an investigation, the appropriate Regional Office issues confirmatory action letters to verify that the utility will not perform additional work on faulty equipment until the utility's troubleshooting plans can be reviewed by the IIT. The Team Leader has the authority to add or remove equipment from the quarantine list.                    The Regional Inspectors and the Regional Office oversee the troubleshooting process and report their results to the IIT.
In interviews with four other nuclear power plant licensees, concern was expressed about equipment unnecessarily quaran-tined that was unrelated to the incident.                    In their view, such equipment should be released as soon as possible to ex-pedite plant recovery work.                    The Westinghouse Owner's Group has expressed the same concern. SECY-85-208 calls for the prompt release of quarantined equipment unrelated to the in-cident, and MC 0513 and IIT training should emphasize this issue. Prolonged quarantining of equipment brings into question the licensee's responsibility for the safe condi-tion of the plant.
6 Quarantining in this context refers to the practice of phys cally removing or otherwise isolating equipment to keep it off limits to unauthorized plant personnel so that infor-mation about the root causes of its malfunction is not lost or inadvertently destroyed by activities subsequent to the incident.
47
 
1 During the Davis-Besse investigation, misunderstandings arose regarding legal representation for utility employees interviewed by the IIT. Some of those questioned felt it necessary to have legal or other representatives present.
    'Although such interviews are conducted on a voluntary basis rather than as the result of subpoenaed appearances, consti-tutional considerations of due process favor granting the interviewee the right to legal representation and the advice of counsel during the interview. Despite the IIT's l    nonadversarial investigation, consequences resulting from it      ,
j    may lead to enforcement actions and, under some circumstanc-es, criminal sanctions.      Because the IIT engages in a fact-finding, nonadjudicative investigation, the participation of    ~
counsel may be limited by the Agency.
Toledo Edison personnel and the NRR Project Manager for Davis-Besse were concerned because normal communications between them concerning pending issues were deferred until completion of the IIT investigation.
The Group examined the role of NRC's Office for the Analysis and Evaluation of Operational Data (AE00) in coordinating the administration of the IIP.      Both SECY-85-208 and MC 0513 identify AE00 as providing administrative support to and liaison between the IIT Leader and the ED0 during an inves-tigation. The three IIT Leaders unanimously stated that the AE00 support role in no way reduced their efforts to conduct a thorough and independent investigation.
The Group considered NRC-Toledo Edison pre-event interaction as it may have been a part of a root cause for the Da-i    vis-Besse incident. The Group's review did not disclose any basis in the Davis-Besse IIT report (NUREG-1154) for alleged superficial licensee management and maintenance practices, nor the foundation for concluding that the incident was i    caused by a lack of attention to detail in the maintenance of plant equipment. An evaluation of NRC-Toledo Edison interaction that might have been associated with the
;    incident was not performed by the Davis-Besse IIT--being i
considered outside of its mandate--but was performed to an extent in the San Onofre and Rancho Seco investigations.          .
l    The Group believes that investigations of pre-event NRC interactions might better be conducted by an Office report-      .
ing to the Commission rather than to the EDO. The Office of the Inspector and Auditor (0IA), which performed a similar function in connection with the Davis-Besse incident, could carry out this responsibility. The OIA, when necessary, could use technical consultants from within and outside the Agency. This approach would still make the IIT responsible for describing the pre-event interaction directly applicable to the event. However, an 0IA role would eliminate any concerns over whether the NRC staff should investigate 48
 
itself or whether an IIT lacks independence because it reports to the EDO.
Use of the Davis-Besse IIT Report by the NRC Staff The NRC Staff Action Plan, which includes some pre-event unresolved items, responded to all the items listed in the Davis-Besse IIT report. The ED0 also directed that a reappraisal of the adequacy of the basic design of B&W
  ,  reactor plants be undertaken. The B&W Owner's Group is  to handle this responsibility, subject to staff review and approval.
On August 5, 1985, an E00 memorandum requested all NRC office directors to conduct an "in-depth and searching reappraisal of the effectiveness of their programs and the lessons learned of the Davis-Besse event." As a result, a      ,
number of substantive staff actions were proposed or initi-ated. The ED0 directed the staff's attention to the follow-ing issues: (1) that safety issues be identified and com-pleted in a timely manner, (2) that the potential for the positive and negative safety impacts resulting from regula-tory actions be considered, and (3) that increased emphasis be given to balance of plant equipment.
In addition to the B&W design reassessment, the results of the EDO and staff director evaluations produced the follow-ing decisions:    (1) an improved issue-tracking and manage-ment system, (2) periodic performance appraisal meetings on operating facilities, (3) development of licensee perfor-mance indicators, and (4) increased regulatory attention to balance of plant and the safety ramifications of regulatory actions.
Follow-on Incident Investigation Team Reviews The Rancho Seco and San Onofre IITs examined, to an extent, the NRC staff-licensee pre-event interactions. In the case of Rancho Seco, the IIT Team Leader noted that although the staff had serious concerns in the past 6 to 8 years about
  . precursors to that event, Rancho Seco management had not implemented the actions required nor had the NRC staff pursued these issues to ensure their implementation. For
  . example, the staff believed that the emergency feedwater initiation and control (EFIC) system would be installed at Rancho Seco in 1984 in response to NRC requirements.      In fact, an alternate system was subsequently installed, but the design was not approved nor made clear to the NRC staff, and may not have complied with NRC requirements.
49
 
;                  Conclusions
;                  The mandate for Incident Investigation Teams is adequate for conducting NRC incident investigations.
The Davis-Besse IIT report would have been enhanced if the 4
team had been instructed to examine pre-event NRC-licensee interactions.                                                                                                            ,
I                  There is need for NRC to conduct seminars or workshops to                                                                .
1 inform licensees in advance of the fundamentals of an NRC l                  incident investigation.                                              (The Group understands that such a i                  program is being considered by AE0D.)                                                                                  ,
The Davis-Besse IIT members possessed adequate technical expertise to comply with the, requirements necessary to
:~
perform their investigative task. The Group endorses a suggestion that IITs receive incident investigation train-i                  ing.
The Davis-Besse IIT report effectively described the se-t                  quence of events of the June 9, 1985 incident. However, the
!                  report's observation that Davis-Besse had a history "of i                  evaluating operating experience related to equipment in a superficial manner," was not supported in the report. The conclusion that the underlying cause of the main and auxil-
:                  iary feedwater event was the licensee's lack of attention to 1                  detail in the care of plant equipment was also not supported
,                  in the report.
l The EDO Action Plan following the incident made adequate use
.                  of the report findings and conclusions.                                                          The EDO Action Plan j                  since it also included the requirement for the NRC staff to reappraise its programs, planning, and actions based upon 3
lessons learned from the Davis-Besse incident.
Unless organizations such as utilities, INPO, EPRI and reactor vendors are involved in the formulation of and are i
familiar with IIT procedures, they may not be willing or prepared to participate in future investigations, t
l                  Recommendations Expedite the development of detailed procedures for the                                                                  -
!                  formation, training, operation, and reporting requirements of future IITs.                          These procedures should clearly define the (a) scope of the investigation and its schedule; (b) mode of l                operation for the team; (c) legal constraints and rights of licensees and employees, including NRC employees; (d) quarantining equipment, with clearly defined roles for the licensee and the Region; and (e) completion of the assign-I ment. These procedures should be developed and coordinated I                with the nuclear power industry, and Agency personnel should                                                                  I i
;                                                                                                  50 i
 
meet with them to explain the role of IITs and how they will function.
Participation on IITs of members from INP0, EPRI, vendors, other utilities, and Federal and State agencies with appli-cable technical expertise, when appropriate, should be encouraged.                                                    ,
The Commission should assign 01A to investigate pre-event
    . interaction between the NRC staff and the licensee as it may be relevant to the root cause of the event.
      . The NRC manual chapter and other appropriate procedures should specify guidelines concerning the role of counsel or other advisors for personnel interviewed by an IIT.
The IIT incident investigation training program should be accelerated and consideration given to extending some of this training to Augmented Inspection Team candidates and other I&E staff members.
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I CHARTER AD-H0c LNDEPENDENT REVIEW GROUP ON THE DAVIS-BESSE INCIDENT The Nuclear Regulatory Commission has decided to establish an independent I                ad by group (the review group) to review issues arising out of the June 9, 1985, incident at the Davis-Besse nuclear power plant. The purpose of this review group is to identify additional lessons that might be learned from
'                the incident, and from these to make reconsnandations as to how NRC's inter-The nel procedures and its oversight of reactor licensees may be improved.
review group shall have the authority necessary to perform the tasks and accomplish the purposes of this charter. By this and other reviews and the implementation of the recommendations arising from them, the Comission intends to reduce the possibility of future similar occurrences.
To this end the review group will undertake the following studies:
a
: a.                  Examine the process of analysis, review, and interaction between the l
licensee and the NRC that took place preceding the event concerning l
the reliability of, and the need and schedule for modification of, the Davis-Besse auxiliary feedwater system and associated systems; and l
make recommendations as to how the regulatory process may be improved I
in light of the findings resulting from this examination.
: b.                    Examine pre-event probabilistic assessments of the reliability of the Davis-Besse plant safety systems, the NRC review of these assessments,
 
l                                        -2 and the use to which these analyses were put in the regulatory decisionmaking process; and make recomendations as to how the use of thYsort of reliability analysis in the regulatory process might be improved.
: c. Examine the licensee's management, operation and maintenance programs to the extent that they may have contributed to the equipment failures that caused or exacerbated the incident; examine the NRC's require-ments for, and oversight of, such lic'ensee programs; and make recom-mandations as to how the NRC may improve its regul}ttory processes and its oversight of reactor licensees in these areas.
: d. Examine the mandate, capabilities of members, operation, and results of the Davis-Besse incident investigation team, and the use to which its report was put by the regulatory staff; and make recomendations as to how the incident investigation process may be improved.
This review is not a vehicle for determining whether Davis-Besse can be The operated in the future without undue risk to public health and safety.
Comission will make that decision through its normal regulatory procedures which are in no way dependent upon the work of this review group.
i l
Therefore, the timing of that decision is in no way related to the work of this review group. However, if the review group identifies information bearing on a significant safety deficiency at Davis-Besse or other licensed facilities, it should bring this to the attention of the EDO.
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  #                                              Similarly, this review should not assess responsibility for the incident on That assessment is the part of individual licensee or NRC staff members.
the respo'nsibility of our Offices of Inspection and Enforcement.
Investigations, and Inspector and Auditor. However, the Comission expects that, if the review group receives any evidence relevant to the issues of culpable responsibility of individuals, such evidence will be provided promptly to the Comission.
The group will determine for itself what methods and procedures other than adjudicatory it will use to gather data. ' Insofar as th'e review group believes previous reviews and analyses to be ad' equate, they should not duplicate the existing work. The EDO is instructed to provide additional Given the technical data regarding the incident as it becomes available.
potential complexity of task (b) above, the Comission will, if the group wishes, provide contractor support funds to assist the review group in its technical analysis of the various probabilistic analyses and the staff The General Counsel and Secretary of the Comission will reviews thereof.
be available for consultation in procedural matters. Facilities and admin-istrative and clerical support will be p'rovided through the resources of the ASLB Panel, with additional support funds anc personnel provided through detailing from the E00 staff. The review group shall determine the non-adjudicatory methods, procedures, and scheoule it will follow to accomplish its responsibilities, and notify the Comission thereof within Within 90 days the review group two weeks of the issuance of this charter.
is to report in writing its findings and recomendations, and to brief the Comission at a public meeting as soon thereafter as practicable.
 
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