ML14113A013

Irmc 300 Incident Investigation

ML14113A013
Person / Time
Issue date:	06/20/2014
From:	Robert Lewis Office of Nuclear Security and Incident Response
To:
Grant J D
References
IRMC 300
Download: ML14113A013 (11)

Text

IRMC 300 INCIDENT INVESTIGATION

APPROVED BY: Robert Lewis EFFECTIVE DATE: 6/20/14

REVISION: 0

ii TABLE OF CONTENTS 1.0 PURPOSE .......................................................................................................................

... 3 2.0 RESPONSIBILITIES AND AUTHORITIES ........................................................................ 3 3.0 LIMITATIONS ...................................................................................................................

.. 4 4.0 ACTIVATING A TEAM ....................................................................................................... 5 5.0 CONDUCTING AN INVESTIGATION ................................................................................ 6 6.0 CONDUCTING INTERVIEWS ........................................................................................... 7 7.0 TREATMENT OF QUARANTINED EQUIPMENT .............................................................. 8 8.0 PREPARATION OF REPORT AND FOLLOW-UP............................................................. 8

3 1.0 PURPOSE The objective of the Incident Investigation Program (IIP) is to ensure that significant events (power reactor, non-power reactor, nuclear materials, or safeguards) are investigated objectively and independently using a systematic and technically sound methodology. In addition, the program enables an Incident Investigation Team (IIT) to gather and analyze information pertaining to the most likely causes of the events, including any NRC contributions or lapses, and to provide appropriate feedback regarding the lessons of experience to the NRC, industry, and public. By focusing on the most likely causes of events and identification of associated corrective actions, the results of the IIP process improve nuclear safety by ensuring a complete technical and regulatory understanding of significant events.

Incident Investigation Teams ensure that significant events are investigated in a manner that is timely, objective, systematic and technically sound; that factual information pertaining to the event is documented; that root and contributing cause(s) are ascertained; and that a complete technical and regulatory understanding of such an event is achieved.

In early 1986, a draft of the guidelines was provided to all the owners, groups, the Institute of Nuclear Power Operations (INPO), and the Nuclear Safety Analysis Center (NSAC) for comment. Between January 29, 1987 and March 11, 1987, The NRC held five regional workshops to acquaint licensees with the IIP. In August 1991, the guidelines were revised to clearly define the roles and responsibilities of the team leader, provide guidance on the follow-up and closeout of NRC staff actions, address lessons learned from incident investigations, and incorporate more current illustrative exhibits. This guidance were also revised to address changes incorporated into NRC Management Directive 8.3, "NRC Incident Investigation Program" and to integrate security-related and safeguards events.

These procedures will foster uniformity, consistency, and thoroughness in IIT investigations, while permitting teams the flexibility to accommodate the diverse nature and scope of future investigations.

2.0 RESPONSIBILITIES AND AUTHORITIES Senior management responsibilities are listed in Management Directives 8.3 and 8.9. The following responsibilities are listed for program implementation. The listed responsibilities may be delegated at the discretion of the listed individual.

Director of Preparedness and Response

• Coordinates with other agency representatives for training purposes.

• Authorizes, when appropriate, temporary deviations from the processes spelled out in this document in order to address higher priority Agency activities and Commission concerns.

4 HQ Coordination Branch Chief

• Provides management review and approval for all document changes to the IR Procedures.

Additional procedural roles are defined within the narrative processes located in implementing procedures (IRP 300 series).

3.0 LIMITATIONS Staff retains the flexibility to enhance or deviate from this manual chapter or its derivative procedures when necessary. However, it is the intent that deviation from this manual chapter and associated procedures be infrequent and approved by NSIR's Director of Preparedness and Response.

5 4.0 ACTIVATING A TEAM

Background

Incident investigation is a formal process conducted for the purposes of identifying and understanding the causes of an accident in order to prevent future accidents of a similar nature. The process includes gathering and analyzing information; determining findings and conclusions, including the cause(s) of a significant event; and disseminating the investigation results for NRC, industry, and public review. The components of the process follow.

Incident Investigation Team (IIT)

This group consists of technical experts who do not have, and have not had, previous significant involvement with licensing and inspection activities at the affected facility and who perform the single NRC investigation of a significant event as defined in section 1.3. An NRC senior manager leads the IIT. Each IIT reports directly to the Executive Director for Operations (EDO) and is independent of regional and headquarters office management. Functionally, the IIT team leader reports to either the Deputy EDO for Reactor and Preparedness Programs, or the Deputy EDO for Materials, Research, State and Compliance Programs. (See Appendix A - Management Directive 8.3)

Augmented Inspection Team (AIT)

This group consists of technical experts from the region in which the incident took place, augmented by personnel from headquarters, other regions or by contractors. The group performs an inspection of a significant event as defined in section 1.3. AIT members should, to the extent practicable, not have recent prior involvement with the facility being inspected, but may have had prior involvement with licensing and inspection activities at the affected facility. The AIT reports directly to the appropriate Regional Administrator (RA). NRC Inspection Procedure 93800, "Augmented Inspection Team," is the procedure for activating and conducting an AIT response, and is maintained by the Office of Nuclear Reactor Regulation (NRR).

Special Inspection (SI)

This inspection is similar to an AIT inspection, except that the group generally is a smaller team (number of members based on management's judgment) and is generally not augmented by personnel from headquarters or other regions. The Special Inspection Team (SIT) reports directly to the appropriate RA. Inspection Procedure 93812 "Special Inspection," provides implementing procedures for Sls.

Specific instructions for activating an incident investigation team can be found in IRP 310.

6 5.0 CONDUCTING AN INVESTIGATION The objectives of the IIT are to:

• conduct a timely, thorough, systematic, and independent investigation of safety-significant events that occur at facilities licensed by NRC;

• collect, analyze, and document the factual information and evidence sufficient to determine the root and contributing causes, conditions, and circumstances pertaining to those events;

and

• determine whether the agency actions taken prior to the event contributed to the cause or course of the event.

To meet these objectives, the investigation includes four major activities:

• collection of data and information;

• analysis and integration of the facts;

• determination of findings and conclusions; and

• preparation and presentation of the team's report.

The associated procedure, IRP 320, is intended to assist the investigation. Team personnel should use their experience, training and those techniques that provide the most confidence in assuring that IIT objectives are achieved.

A detailed team charter delineating the scope of the investigation will be provided to the IIT leader. Further details on the investigation scope are provided in Section 2.2 of IRP 310.

7 6.0 CONDUCTING INTERVIEWS This section provides guidance to ensure interviews are conducted in a uniform, systematic and

complete manner.

Background

Planning on the part of the interviewer is necessary to conduct the interview systematically. The IIT interviewer should have a prepared list of questions for each interviewee. Some predetermined questions concerning suspect areas should be asked of all interviewees.

Prior to conducting interviews, the IIT should have been briefed and given an escorted plant tour to obtain an understanding of what occurred and to obtain a general working knowledge of the location and layout. Interviews should be conducted as soon as possible after the entrance meeting and plant tour to minimize information lost over time from the memories of those involved. High priority should be given to interviewing personnel on duty at the time of the event to learn about the actions they took and the observations they made.

Most interviews are transcribed by a stenographer to ensure that an accurate record of the interview is obtained, and for the convenience of the IIT. For those interviews that are transcribed, ensure that the interviewee understands that the transcripts will be transmitted to the NRC's Public Document Rooms where they will be available to the public. When the team writes its report, an accurate, factual record is available to determine the findings and to make conclusions regarding the event. The necessity for note taking is minimized during the interview, which also eliminates contradictory and erroneous information that can result from note taking.

Team members can give their undivided attention to understanding the observations and actions of the interviewee during the event. However, team members should take notes in order

to provide the team with immediate information, as transcripts may take one or two days to prepare. Explanatory sketches, diagrams, photographs, or written statements are valuable supplements to the interviewee's statements; however, they should not be construed as substitutes for the narrative statement. In general, discussions between the IIT and licensee personnel about routine administrative matters and/or subsequent minor follow-up questions for clarification do not necessarily have to be transcribed. In those limited cases where the team leader deems it inappropriate to transcribe an interview (i.e., the presence of a stenographer

would be detrimental to free flow of information), the team should still conduct the interview as outlined in Section 3.5 of IRP 330, taking detailed notes documenting the conversations between the team and interviewee.

Specific instructions for conducting interviews can be found in IRP 330.

8 7.0 TREATMENT OF QUARANTINED EQUIPMENT This section provides guidance for equipment and areas to be quarantined and related troubleshooting action plans (TAPs) during an IIT investigation.

Attention At all times, the licensee is responsible for quarantined equipment and areas and can take

action involving the equipment and areas that it deems necessary to:

• achieve or maintain safe plant conditions,

• prevent further equipment degradation, or

• test or inspect as required by the plant's Technical Specifications.

To the maximum degree possible, these actions should be coordinated with the IIT leader in advance or notification made as soon as practical.

Background

To learn how equipment failed or performed in an anomalous manner during an event, the IIT must minimize the potential that the equipment could be manipulated such that important information concerning its performance during the event could be lost. Thus, the Regional Administrator confirms that the licensee has quarantined the equipment in its "as-found" condition, usually through a Confirmatory Action Letter (CAL). Then the licensee develops a detailed troubleshooting action plan for systematic inspection and troubleshooting of the equipment in order to identify the probable causes for its failure or observed performance. After the probable cause(s) of failure of a particular component or piece of equipment is determined, the equipment is released from quarantine. Instances also could occur at facilities where areas need to be quarantined in order to preserve radiological conditions, damage conditions or other conditions in order to properly reconstruct the event. Hereinafter, the use of the word "equipment" should be interpreted to mean "equipment and areas."

The CAL confirms the licensee's intention/plans, among other things, that any equipment that may have malfunctioned during the event be preserved, except as required for safety in its present condition. Thus, the licensee is to hold in abeyance all work (i.e., maintenance/testing, etc.) in progress or that is planned for the equipment. The IIT leader is authorized to define and revise the quarantined equipment list (QEL), and to review and approve TAPs.

Specific instructions for treatment of quarantined equipment can be found in IRP 340.

9 8.0 PREPARATION OF REPORT AND FOLLOW-UP This section provides guidance for the preparation, release and distribution of the Incident Investigation Team (IIT) report and follow-up staff actions resulting from the investigation.

Background

The purpose of the incident investigation report is to document in clear and concise language the results of the IIT investigation. The Office of the Executive Director of Operations (EDO) will coordinate with the Director of the Office of Administration to provide staff to assist team members in writing, editing, word processing and printing of the report through the Division of Administrative Services. Follow-up staff actions directed by the EDO will be based on the report findings and conclusions.

Specific instructions for preparing the incident investigation report and subsequent follow-up actions can be found in IRP 350.

10 REVISION LOG Revision Number Effective Date Pages Affected Description of Revision 0 XX/XX/XX All Initial Issue

10 REVISION LOG Revision Number Effective Date Pages Affected Description of Revision 0 XX/XX/XX All Initial Issue

ADAMS ACCESSION No.: ML14113A013 OFFICE NSIR/DPR/CB NSIR/DPR/CB/IROC NSIR/DPR NAME JGrant CEinberg RLewis DATE 04/30/14 05/6/14 05/ /14 OFFICIAL RECORD COPY