IR 05000220/2006011

From kanterella
Revision as of 08:25, 23 January 2018 by StriderTol (talk | contribs) (Created page by program invented by StriderTol)
(diff) ← Older revision | Latest revision (diff) | Newer revision → (diff)
Jump to navigation Jump to search

Download: ML070440231

Text

February 13, 2007

EA-07-001 Mr. Timothy J. O'ConnorVice President Nine Mile Point Nine Mile Point Nuclear Station, LLC P.O. Box 63 Lycoming, NY 13093

SUBJECT: NRC LICENSED OPERATOR REQUALIFICATION PROGRAM INSPECTIONREPORT 05000220/2006011 AND 05000410/2006011; PRELIMINARY WHITE FINDING - NINE MILE POINT NUCLEAR STATION

Dear Mr. O'Connor:

During the period October 16, 2006 through January 9, 2007, the US Nuclear RegulatoryCommission (NRC) conducted an inspection of the Nine Mile Point Nuclear Station Licensed Operator Requalification Program activities. The enclosed report documents the inspection findings, which were discussed on January 18, 2007 in an onsite exit meeting with you and members of your staff.The inspection examined activities conducted under your license as they relate to safety andcompliance with the Commission's rules and regulations and with the conditions of your license.

The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel. The inspection consisted of a review of the licensed operator requalification program. Findings identified during the inspection are discussed in detail in the enclosed inspection report.This report documents a preliminary White finding that appears to have low to moderate safetysignificance. As described in Section 1.R11 of this report, your Licensed Operator Requalification Training Program allowed operating crews to validate simulator exam scenarios that were substantially the same as those that were later administered to these crews as part of their annual operating test. This shortcoming had the unintentional effect of compromising your Unit 1 2005 and 2006 dynamic simulator exam scenarios. The apparent compromise of the 2005 Unit 1 simulator exam scenarios is considered more serious and the basis for the preliminary White finding since the apparent compromise was not corrected by Constellation prior to returning licensed operators to normal duties. In contrast, for the 2006 exam compromise problems Constellation took remedial actions by retesting all operators prior to the end of the exam cycle. This finding was assessed using the Operator Requalification Human Performance Significance Determination Process as a potentially safety significant finding that was preliminarily determined to be White; i.e., a finding with some increased importance to safety, which may require additional NRC inspection. The issue has a low to moderate safety significance because it represented a failure to recognize and correct an apparent examination compromise of the 2005 Unit 1 simulator exam scenarios, and a subsequent return to normal T. O'Connor2watch-standing duties by the licensed operators without adequate compensatory actions for thecompromised examinations. This finding was not an immediate safety concern for the following reasons: (1) there were no significant plant performance issues related to operator knowledge and abilities; (2) all licensed operators had participated in a continuous requalification training program; (3) this issue, while pervasive, was limited to the 2005 and 2006 exams and did not extend to the 2004 exams; and (4) Constellation took immediate remedial actions by invalidating the simulator exam scenario portion of the 2006 annual operating exams and administering new and more comprehensive simulator exam scenarios to all licensed operators upon discovery of this concern by the NRC. The finding is also an apparent violation of NRC requirements and is being considered forescalated enforcement action in accordance with the Enforcement Policy, which can be found on the NRC's web site at http://www.nrc.gov/reading-rm/adams.html.Before we make a final decision regarding the preliminary White finding, we are providing youan opportunity (1) to attend a Regulatory Conference where you can present to the NRC your perspective on the facts and assumptions the NRC used to arrive at the finding and assess its significance, or (2) submit your position on the finding to the NRC in writing. If you request a Regulatory Conference, it should be held within 30 days of the receipt of this letter and we encourage you to submit supporting documentation at least one week prior to the conference in an effort to make the conference more efficient and effective. If a Regulatory Conference is held, it will be open for public observation. If you decide to submit only a written response, such submittal should be sent to the NRC within 30 days of the receipt of this letter.Please contact Mr. Marvin Sykes at (610) 337-5046 within 10 business days of the date of yourreceipt of this letter to notify the NRC of your intentions. If we have not heard from you within 10 days, we will continue with our significance determination and enforcement decision and you will be advised by separate correspondence of the results of our deliberations on this matter.Since the NRC has not made a final determination in this matter, no Notice of Violation is beingissued for this inspection preliminary White finding at this time. In addition, please be advised that the number and characterization of the apparent violation described in the enclosed inspection report may change as a result of further NRC review.In addition, the report documents three NRC-identified findings of very low safety significance(Green). One of these findings was determined to involve a Unit 2 violation of NRC requirements involving similar but less significant exam compromise issues to those identified for Unit 1 for reasons detailed in the enclosed report. The unintentional 2006 Unit 2 simulator exam scenario compromise was assessed separately due to Unit 1 and 2 plant design differences that require unique training programs for each unit, as well as unique plant and operator licenses. However, because of the very low safety significance and because it is entered into your corrective action program, the NRC is treating the Unit 2 exam compromise finding as a non-cited violation (NCV) consistent with Section VI.A.1 of the NRC Enforcement Policy. If you contest this NCV, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington DC 20555-0001; with copies to the Regional Administrator, Region I; the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at Nine Mile Point Nuclear Station.

T. O'Connor3In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and itsenclosure will be available electronically for public inspection in the NRC Public DocumentRoom or from the NRC's document system (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html.

Sincerely,/RA/A. Randolph Blough, DirectorDivision of Reactor SafetyDocket No:50-220, 50-410License No: DPR-63, NPF-69

Enclosure:

Inspection Report 05000220/2006011 and 05000410/2006011

SUMMARY OF FINDINGS

IR 05000220/2006-011, 05000410/2006-011; 10/16/06 - 1/09/07; Nine Mile Point, Units 1 and2; Licensed Operator Requalification Program, Inspection Procedure Attachment 71111.11.This inspection was conducted by two NRC region-based inspectors and two inspectors underinstruction. Three Green findings and one Apparent Violation (AV) with potential safety significance greater than Green, were identified. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609,

"Significance Determination Process" (SDP). Findings for which the SDP does not apply may be Green or be assigned a severity level after NRC management review. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 3, dated July 2000. A.NRC-Identified and Self-Revealing Findings

Cornerstone: Mitigating Systems

  • TBD. An apparent violation of 10 CFR 55.49, "Integrity of Examinations andTests," was identified, concerning an apparent compromise of the 2005 and the 2006 annual operating exams at Unit 1. NRC inspectors identified practices that collectively had the impact of compromising, albeit unintentionally, the examinations; these practices included: 1) a lack of simulator exam scenario diversity (i.e., The scenarios were substantially the same including: critical tasks; major transients; Emergency Operating Procedure flow paths; and emergency classifications); 2) an overuse of a single emergency operating procedure strategy (i.e., full core Anticipated Transient Without Scram); and 3) a pattern of crews validating scenarios substantially similar to their exam scenario sets.

Constellation had not identified and compensated for the compromise prior to completing the 2005 exam and returning the operators to normal control room duties. Following NRC identification of the compromise in 2006, Constellation took immediate and substantive corrective actions prior to completion of the annual operating exam cycle. Based on the Licensed Operator Requalification Significance Determination Process (SDP) this finding was preliminarily determined to be of low to moderate safety significance (White). The licensee initiated Condition Report CR-NM-2006-4808, dated October 19, 2006, that documented this issue and later initiated a Category I Root Cause Analysis (CR-NM-2006-4808), "Annual Licensed Operator Requalification Exam Compromise." This finding was more than minor because it was associated with the HumanPerformance attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the combined objective of: limiting the likelihood of; ensuring the availability and reliability of mitigating systems to respond to; and providing reasonable assurance that physical barriers protect the public from radio-nuclide releases caused by, initiating events.The finding has a cross-cutting aspect in the area of problem identification andresolution because Constellation did not effectively collect, evaluate, and Enclosureiiicommunicate applicable external operating experience to affected internalstakeholders nor did they conduct self-assessments that were comprehensive, appropriately objective, and self-critical such that either Unit 1 2005 exam compromise issues were avoided altogether or identified and corrected prior to the end of the 2005 annual operating exam cycle. (Section 1R11.1)*Green. A Green NRC-identified non-cited violation (NCV) of 10CFR55.49 wasidentified, concerning an apparent compromise of the 2006 annual operating requalification examinations at Unit 2. NRC inspectors identified practices that collectively had the impact of compromising, albeit unintentionally; the examinations, these practices included: 1) a lack of simulator exam scenario diversity (i.e., The scenarios were substantially the same including: critical tasks; major transients; Emergency Operating Procedure flow paths; and emergency classifications); 2) an overuse of a single emergency operating procedure strategy (i.e., full core Anticipated Transient Without Scram); and 3) a pattern of crews validating scenarios substantially similar to their exam scenario sets. The licensee initiated CR-NM-2006-4808 that documented this concern and later initiated a Category I Root Cause Analysis.This finding was more than minor because it was associated with the HumanPerformance attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the combined objective of: limiting the likelihood of; ensuring the availability and reliability of mitigating systems to respond to; and providing reasonable assurance that physical barriers protect the public from radio nuclide releases caused by, initiating events. The finding was assessed as having very low safety significance because immediate and substantive corrective actions were taken by Constellation prior to the end of the current exam cycle. The finding has a cross-cutting aspect in the area of problem identification andresolution because Constellation did not effectively collect, evaluate, and communicate applicable external operating experience to affected internal stakeholders nor did they conduct self-assessments that were comprehensive, appropriately objective, and self-critical such that the 2006 Unit 2 exam compromise issues were either avoided altogether or at least identified and corrected by Constellation prior to the start of this inspection. (Section 1R11.2)*Green. A finding of very low safety significance was identified at Unit 1. Thefinding was associated with crew performance on the simulator during the 2006 facility-administered requalification examinations. Of the six crews evaluated, two failed to pass their simulator examinations when the newly developed more comprehensive exams were re-administered in response to the above noted preliminary White finding. The failures are documented in licensee-initiated Condition Report CR 2006-5797, which resulted in Constellation conducting a Category I Root Cause Analysis. This finding was more than minor because it was associated with the HumanPerformance attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the combined objective of: limiting the Enclosureivlikelihood of; ensuring the availability and reliability of mitigating systems torespond to; and providing reasonable assurance that physical barriers protect the public from radio nuclide releases caused by, initiating events. The finding was assessed as having very low safety significance because: 1) the failures occurred during annual testing of the operators on the simulator; 2) there were no actual consequences to the failures; 3) the crews were removed from watch standing duties, retrained and re-evaluated before they were authorized to return to control room watches; and, 4) because the crew failure rate for the 2005 Unit 1 Annual Operating Exams was less than 20%. (Section 1R11.3)*Green. A finding of very low safety significance was identified at Unit 2. Thefinding was associated with crew performance on the simulator during the 2006 facility-administered requalification examinations. Of the six crews evaluated, two failed to pass their simulator examinations when the newly developed more comprehensive exams were re-administered in response to the above noted preliminary White finding. The failures are documented in licensee-initiated Condition Report CR 2006-5797, which resulted in Constellation conducting a Category I Root Cause Analysis. This finding was more than minor because it was associated with the HumanPerformance attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the combined objective of: limiting the likelihood of; ensuring the availability and reliability of mitigating systems to respond to; and providing reasonable assurance that physical barriers protect the public from radio nuclide releases caused by, initiating events. The finding was assessed as having very low safety significance because: 1) the failures occurred during annual testing of the operators on the simulator; 2) there were no actual consequences to the failures; 3) the crews were removed from watch standing duties, retrained and re-evaluated before they were authorized to return to control room watches; and, 4) because the crew failure rate for the 2005 Unit 2 Annual Operating Exams was less than 20%. (Section 1R11.4)B.Licensee-Identified FindingsNone.

Enclosure

REPORT DETAILS

1.REACTOR SAFETY1R11Licensed Operator Requalification Program (71111.11)

a. Inspection Scope

The following inspection activities were performed using NUREG-1021, Rev. 9,"Operator Licensing Examination Standards for Power Reactors," Inspection Procedure 71111.11, "Licensed Operator Requalification Program," and NRC Manual Chapter 0609, Appendix I, "Operator Requalification Human Performance Significance Determination Process (SDP)," as acceptance criteria. During the first onsite inspection week of October 16, 2006, inspectors observedadministration of licensed operator requalification exams on Unit 1, including two dynamic simulator scenarios, three simulator Job Performance Measures (JPMs) and two in plant JPMs for one operations crew. Following an NRC debrief on the preliminary inspection issues identified, the licensee invalidated all of the dynamic simulator exams for 2006 on both units and initiated development of new 2006 exam scenarios (see Findings section of this report for further details). As a result of these identified issues the scope of this inspection was expanded.

During the weeks of November 20, December 4 and December 11, 2006, the inspectors observed and assessed Constellation's administration of newly developed exam scenarios to all six of the Unit 1 operating crews and two of the Unit 2 operating crews.

In addition, the inspectors observed the administration of retake exam scenarios for one Unit 1 and one Unit 2 operating crew following their exam failures and subsequent training remediations. The inspectors reviewed all three Unit 1 exam sets for both the comprehensive ReactorOperator (RO) and Senior Reactor Operator (SRO) biennial written exams, as well as all the newly developed simulator exam scenarios for both Unit 1 and 2, and a sample (i.e.,

exam weeks 1, 3, 4) of the Unit 1 JPMs administered during this current exam cycle to ensure the quality of these exams met or exceeded the criteria established in the Examination Standards and 10 CFR 55.59. In addition, both the Unit 1and 2 simulator exam scenarios administered as part of the 2005 annual operating exams were reviewed and evaluated as part of an exam compromise extent of condition review. Simulator performance was evaluated through observation during the conduct of theexaminations, a review of simulator performance tests (e.g., steady state performance tests, selected transient tests, and selected scenario-based tests), and a review of Simulator Deficiency Reports to verify compliance with the requirements of 10 CFR 55.46 and guidance contained in ANSI/ANS-3.5-1998. Corrective actions were reviewed associated with NCV 2004005-02 (Failure of NMP Simulator to Demonstrate Expected Plant Response). No significant simulator issues were identified (see document list attached).

2EnclosureThe inspectors reviewed documentation of operating history since the last requalificationprogram inspection. The inspectors also discussed facility operating events with the resident staff. Documents reviewed included NRC inspection reports, Plant Performance Insights, licensee event reports (LERs), and licensee condition reports (CRs) that involved human performance issues for licensed operators to ensure that operational events were not indicative of possible training deficiencies.The following record reviews were conducted: remediation plans for seven cyclic writtenexam failures and one evaluated Operating Exam segment; seven medical records; eight quarters of time on shift records; and, ten operator license reactivations. On January 9, 2007, the inspectors conducted an in-office review of the fullrequalification exam results to assess whether pass rates were consistent with the guidance of NRC Manual Chapter 0609, Appendix I, "Operator Requalification Human Performance Significance Determination Process (SDP)." Results are listed below.Unit 1 Results:*Crew failure rate on the dynamic simulator was less than 34%. The threshold fora Green finding is a failure rate between 20% and 33%.

(Failure rate was 33.33%.)*Individual failure rate on the dynamic simulator test was less than or equal to20%. (Failure rate was 19.0%.)*Individual failure rate on the walk-through test (JPMs) was less than or equal to20%. (Failure rate was 2.4%.)*Individual failure rate on the comprehensive biennial written exam was less thanor equal to 20%. (Failure rate was 2.4%)*More than 75% of the individuals passed all portions of the exam (78.5% of theindividuals passed all portions of the exam).Unit 2 Results:*Crew failure rate on the dynamic simulator was less than 34%. The threshold fora Green finding is a failure rate between 20% and 33%.

(Failure rate was 33.33%.)*Individual failure rate on the dynamic simulator test was less than or equal to20%. (Failure rate was 12.5%.)*Individual failure rate on the walk-through test (JPMs) was less than or equal to20%. (Failure rate was 0.0%.)

3Enclosure*Individual failure rate on the comprehensive biennial written exam was less thanor equal to 20%. (Not applicable - not administered this year)*More than 75% of the individuals passed all portions of the exam (87.2% of theindividuals passed all portions of the exam).

b. Findings

1.Failure to Ensure Integrity of Unit 1 Examinations and TestsIntroduction. An apparent violation of 10 CFR 55.49, "Integrity of Examinations andTests," was identified, concerning an apparent compromise of the 2005 and the 2006 annual operating exams at Unit 1. Constellation had not identified and compensated for the compromise prior to completing the 2005 exam and returning the operators to normal control room duties. Following NRC identification of the compromise in 2006, Constellation took immediate and substantive corrective actions prior to completion of the annual and biennial operating exam cycles. Based on the Licensed Operator Requalification Significance Determination Process (SDP) this was preliminarily of low to moderate safety significance (White).Description. The inspectors identified that the exam practices used by Constellation atNine Mile Point resulted in an apparent compromise of the simulator exam scenario portion of both the 2005 and 2006 annual operating tests. The apparent compromise is considered widespread, because all licensed operator requalification crews were affected on both the 2005 and 2006 exams. The apparent compromise of the 2005 Unit 1 simulator exam scenarios is considered more serious than the 2006 exam compromises and the basis for the preliminary White finding since the 2005 apparent exam compromises were not corrected by the licensee prior to returning licensed operators to normal watch-standing duties. In contrast, in 2006 when the exam compromises were identified by the NRC and brought to the attention of Constellation remedial actions were taken to retest all of the operators prior to the end of the exam cycle.The issue was identified while conducting the Unit 1 biennial Licensed OperatorRequalification Training (LORT) Program inspection during the week of October 16, 2006. Constellation allowed operating crews to validate simulator exam scenarios that were substantially the same as the simulator exam scenarios that were later administered to these crews as part of their annual operating test, thus preconditioning the operators. These practices did not comply with Constellation's procedural guidance, NMP-TR-1.01-20, Attachment 5, Section B.2 states, "Personnel shall not validate any materials to be used on their exams," and Section D stipulates each section of the requalification exams will contain at least 50% new material.

4EnclosureThe inspectors identified that the scenarios validated by Unit 1 "A" crew (September 12-16, 2006) were substantially similar in content to the two simulator exam scenarios that were administered to "A" crew on October 17, 2006. With the exception of a few malfunctions, the scenarios were substantially the same, i.e., the same critical tasks, major transients, Emergency Operating Procedure (EOP) flow paths, and emergency classifications. In addition, on October 16, 2006, one day before taking their annual operating test using scenario #4, "A" crew was administered exam scenario #2 for validation/practice. The inspectors determined that scenario #2 was substantially the same as scenario #4. The inspectors determined that the other crews examined during the first three weeks of the exam cycle had also validated scenarios that were substantially similar in content to the simulator exam scenarios administered during their exam weeks.The inspection team further noted that twelve of the sixteen new simulator examscenarios developed for the Unit 1 2006 annual operating test cycle involved a full core Anticipated Transient Without Scram (ATWS) theme and varied primarily by changing several malfunctions for each scenario. This lack of exam diversity, an overuse of the ATWS theme, and a pattern of crews validating scenarios substantially similar to their exam scenario sets collectively had the effect of compromising the exams. In addition, the over-emphasis on examining the ATWS theme resulted in not testing other important EOP mitigation strategies (e.g., secondary containment and radiation release strategies). Furthermore, the inspectors determined that the scenario exam sets previously administered during weeks 1 and 2 were scheduled to be re-administered during exam weeks 5 and 6 respectively.The NRC inspection team communicated these issues to Constellation representatives. On October 20, 2006, representatives of Constellation management agreed with the NRC inspection team's assessment of the issues. Constellation determined that the 2006 Unit 1 and 2 annual license simulator exam scenarios administered to date were invalid due to the pervasive nature of the apparent exam compromise. Exam administration was suspended at both units pending development of new exams. The licensee initiated Condition Report CR-NM-2006-4808, dated October 19, 2006 that documented this issue and later initiated a Category I Root Cause Analysis (CR-NM-2006-4808), "Annual Licensed Operator Requalification Exam Compromise." Note: A Category I Root Cause Analysis is conducted by independent parties, involves a thorough investigation of the details that led to the problem, identifies the root as well as contributing causes, and assigns corrective actions to prevent re-occurrence of the problem.

Following the onsite visit, the NRC inspection team conducted an in-office extent ofcondition review of the Unit 1 2005 simulator exam scenario portion of the annual operating tests. The team determined that the 2005 simulator exam scenarios were compromised and this problem went undetected and uncorrected by the licensee. The problem remained undetected until it was identified by the NRC and brought to the attention of Constellation. The problems with the 2005 simulator exam scenarios were similar to those identified on the 2006 dynamic exams and included a lack of exam diversity, an overuse of the ATWS theme (8 of 11 scenarios), and a pattern of crews 5Enclosurevalidating scenarios that were substantially similar to their exam scenario sets. Incontrast to the 2006 exam, the compromise to the simulator scenario exam portion of 2005 annual operating test was undetected and uncorrected, led to licensed operators returning to normal watch-standing duties without adequate compensatory actions being taken and therefore, is the basis for the preliminary White finding.Inspectors conducted interviews with the exam development team and reviewedassociated development records for the 2005 and 2006 exams. Based on this review, it appeared that the exam compromise issue resulted from NMP staff inexperience and lack of management oversight of the exam development process. Constellation's emphasis on maintaining exam security resulted in self-imposed restrictions on management oversight of the exam development process. In addition, the exam development team operated under some misconceptions including: 1) due to a recent upgrade to the simulator model, rather than modifying existing exam scenarios, the exam team needed to draft all new simulator exam scenarios; 2) all revisions to exam scenarios had to be validated by an operating crew which, in some cases, resulted in multiple crew exposures to a single scenario; 3) minor revisions to an exam scenario were enough to consider the scenario sufficiently unique to be considered a new scenario; 4) it is acceptable for a crew to validate a simulator exam scenario substantially the same as their exam scenario, provided this is done six weeks in advance; and 5) each exam had to include events which challenged one or more critical tasks from a small pre-existing list of critical tasks which did not encompass the full range of major events. These misconceptions resulted in a narrowly focused exam which over-tested the ATWS theme at the exclusion of other equally important EOP mitigation strategies. The inspectors did not find any indication that the compromises were intentional.The licensee's root cause team later concluded, "...that similarities in the scenarios inthe 2006 Unit 1 exam set caused unintentional preconditioning of the crew by exposing them to scenarios during validation that were essentially the same as the scenarios used for their exam ... and reviewed the 2005 Unit 1 exam sets and found issues similarto those associated with the 2006 Unit 1 exam." The root cause team identified two primary causes: 1) policy guidance, management expectations, and job performance standards were not well-defined or understood, the process provides minimal direction and guidance, which the inexperienced team was not able to compensate for through their knowledge; and 2) a rigorous review and analysis of the exam by an experienced exam author did not occur during the review/challenge process. No one outside the immediate exam development team performed a comprehensive exam set review.New and more comprehensive simulator scenario exams were developed andadministered to all licensed operators between November 20 and December 14, 2006.

The inspection team observed the re-testing of all Unit 1 licensed operators and noted the following improvements: 1) development and administration of new, more comprehensive simulator exam scenarios; 2) one-on-one operator evaluations; 3)rotating watch positions for the SROs as well as the ROs between scenarios; 4)evaluation of Shift Technical Advisor position; and 5) conducting more detailed post exam critiques.

6EnclosureAnalysis. The unintentional integrity comprise of the simulator exam scenario portion ofthe Unit 1 2005 and 2006 annual operating exams was a performance deficiency, in that Constellation failed to follow their established requalification procedures and resulted in an apparent violation of 10 CFR 55.49. "Integrity of Exams and Tests." Specifically, in 2005 and initially in 2006 the operators were tested using requalification simulator exam scenarios substantially similar to simulator exam scenarios that they had previously validated. Therefore, the validation process, in combination with a lack of exam diversity, caused exam integrity to be compromised. Traditional enforcement does not apply because the issue did not have any actual safety consequences, potential for impacting the NRC's regulatory function, and was not the result of any willful violation of NRC requirements or Constellation's procedures. This finding was more than minor because it was associated with the Human Performance attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the combined objective of: limiting the likelihood of; ensuring the availability and reliability of mitigating systems to respond to; and providing reasonable assurance that physical barriers protect the public from radio nuclide releases caused by, initiating events.This finding was determined preliminarily to have low to moderate safety significance(White) using the Licensed Operator Requalification Human Performance Significance Determination Process (SDP) Inspection Manual Chapter 0609, Appendix I. Block 21 applies, "Has the integrity of the scenario been compromised? This is a failure to control the scenario identity or material including the- validation process such that the operating test integrity is affected". The answer to the Block 21 question is "yes", the operators were tested using requalification exam scenarios substantially similar to exam scenarios that they had previously validated. Therefore, the validation process, in combination with a lack of scenario diversity, led to an unintentional exam compromise.Block 26 also applies, "When the compromise was discovered, or should have beendiscovered, did the licensee take immediate compensatory measures". The answer tothe Block 26 question is "no", as Constellation did not identify and take immediate corrective actions for the 2005 Unit 1 exam compromises (Block 21 - Yes and Block 26 -

No). This simulator exam scenario integrity compromise finding should have been discovered and corrected by Constellation, prior to NRC identification. Constellation should have discovered the problem in 2005 or at least prior to the NRC's identification because: 1) a similar issue was described in 2002 Industry Operating Experience involving exam compromise; 2) Constellation completed a self audit in August 2006 that failed to identify this issue; and 3) the practices clearly violated NRC guidance and requirements, as well as Constellation's procedural guidance aimed at preventing exam compromise. More importantly, however, in 2005, because the issue was not identified at the time, Constellation had not taken compensatory actions prior to returning the operators to normal control room duties. Following identification of this issue by the NRC, the licensee took immediate and substantive corrective actions to remedy the 2006 annual operating exam compromise, by developing new exams and re-testing all the Unit 1 licensed operators within the required annual and biennial exam cycles. The cause of the finding has a cross-cutting aspect in the area of problem identificationand resolution in that Constellation did not effectively collect, evaluate, and 7Enclosurecommunicate applicable external operating experience to affected internal stakeholdersnor did they conduct self-assessments of sufficient depth that were comprehensive, appropriately objective and self-critical such that the Unit 1 2005 exam compromise issues were avoided altogether or at least identified and corrected prior to the end of the 2005 annual operating exam cycle.

Enforcement.

10 CFR 55.49, requires, in part, that, "...licensees shall not engage in anyactivity that compromises the integrity of any application, test, or examination required by this part. The integrity of a test or examination is considered compromised if any activity, regardless of intent, affected, or, but for detection, would have affected the equitable and consistent administration of the test or exam." Contrary to this requirement, the Unit 1 2005 and 2006 annual operating tests were compromised since the process used to validate the simulator exam scenarios resulted in licensed operators being knowledgeable of a significant portion of the test prior to its administration.This finding was not an immediate safety concern for the following reasons: 1) therewere no significant plant performance issues related to operator knowledge and abilities; 2) all licensed operators had participated in a continuous requalification training program; 3) this issue, while pervasive, was limited to the 2005 and 2006 exams and did not extend to the 2004 exams; 4) Constellation took immediate remedial actions by administering new and more comprehensive simulator exam scenarios to all Unit 1 licensed operators upon discovery of this concern by the NRC. Some individual and crew weaknesses were identified, as evidenced by the individual and crew failure rates,however the performance on these new exams was overall satisfactory. (AV 50-220/2006011-01, Failure to Ensure Integrity of Unit 1 Examinations and Tests)2.Failure to Ensure Integrity of Unit 2 Examinations and TestsIntroduction. A non-cited violation of 10 CFR 55.49, "Integrity of Examinations andTests," was identified, concerning an apparent compromise of the 2006 annual operating exams at Unit 2. Following NRC identification of the compromise, Constellation took adequate compensatory measures, prior to completion of the annual and biennial exam cycles.Description. The inspectors identified that the exam practices used by Constellation atNine Mile Point resulted in an apparent compromise of the dynamic scenario portion the 2006 annual operating tests.The issue was identified while conducting the Unit 1 biennial LORT Program inspectionduring the week of October 16, 2006. Constellation allowed operating crews to validate simulator exam scenarios that were substantially the same as the simulator exam scenarios that were later administered to these crews as part of their annual operating test, thus preconditioning the operators (see preliminary white finding discussed in item b.1 above for details). These practices did not comply with Constellation's procedural guidance, in NMP-TR-1.01-20, Attachment 5, Section B.2 which states, "Personnel shall not validate any materials to be used on their exams," and Section D which stipulates 8Enclosureeach section of the requalification exams will contain at least 50% new material.The NRC inspection team communicated these issues to Constellation representatives. On October 20, 2006, representatives of Constellation management agreed with the NRC inspection team's assessment of the issues. The licensee then conducted an extent of condition review for Unit 2 annual license operating tests administered to date and determined the exams administered to date were invalid due to the pervasive nature of the apparent exam compromise. Exam administration was suspended at both units pending development of new exams. The licensee initiated Condition Report CR-NM-2006-4808, dated October 19, 2006 that documented this issue and later initiated a Category I Root Cause Analysis (CR-NM-2006-4808), "Annual Licensed Operator Requalification Exam Compromise."Following the onsite visit, the NRC inspection team conducted an in-office extent ofcondition review of the Unit 2 2005 dynamic operating tests. The team determined that the 2005 Unit 2 dynamic exams were not affected.The licensee's root cause team later concluded, "...that similarities in the scenarios inthe 2006 Unit 1 exam set caused unintentional preconditioning of the crew by exposing them to scenarios during validation that were essentially the same as the scenarios used for their exam ... and reviewed the 2006 Unit 2 and 2005 Unit 1 exam sets and found issues similar to those associated with the 2006 Unit 1 exam." New and more comprehensive scenario exam scenarios were developed andadministered to all licensed operators between November 20 and December 14, 2006.

The inspection team observed the re-testing of all Unit 1 and some of the Unit 2 licensed operators.Analysis. The unintentional integrity compromise of the simulator exam scenario portionof the 2006 Unit 2 annual operator exams was a performance deficiency, in that Constellation failed to follow their established requalification procedures and violated 10 CFR 55.49. "Integrity of Exams and Tests." Specifically, initially in 2006 the operators were tested using simulator exam scenarios substantially similar to simulator exam scenarios that they had previously validated. Therefore, the validation process, in combination with a lack of exam diversity, caused exam integrity to be compromised.

Traditional enforcement does not apply because the issue did not have any actual safety consequences or potential for impacting the NRC's regulatory function and was not the result of any willful violation of NRC requirements or Constellation's procedures. This finding was more than minor because it was associated with the Human Performance attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the combined objective of: limiting the likelihood of; ensuring the availability and reliability of mitigating systems to respond to; and providing reasonable assurance that physical barriers protect the public from radio nuclide releases caused by, initiating events.This finding was determined to have very low safety significance (Green) usingAppendix I of the SDP. Block 21 applies, "Has the integrity of the scenario been 9Enclosurecompromised? This is a failure to control the scenario identity or material includingthe- validation process such that the operating test integrity is affected." The answer to the Block 21 question is "yes", the operators were tested using requalification exam scenarios substantially similar to exam scenarios that they had previously validated.

Therefore, the validation process in combination with a lack of scenario diversity, led to an exam compromise. Block 26 also applies, "When the compromise was discovered, or should have been discovered, did the licensee take immediate compensatory measures" also applies. The answer to the Block 26 question is "yes" resulting in a green finding (Block 21 - Yes and Block 26 - Yes), This simulator exam scenario integrity compromise finding should have been discovered and corrected prior to NRC identification. However, following identification Constellation took immediate and substantive compensatory actions to remedy the 2006 annual operating exam compromise, by developing new exams and re-testing all the Unit 2 licensed operators within the required annual and biennial exam cycles. Further, the inspectors verified that the Unit 2 2005 simulator exam scenario portion of the annual operating exam had not been compromised in a similar fashion. The cause of the finding has a cross-cutting aspect in the area of problem identificationand resolution in that Constellation did not effectively collect, evaluate, and communicate applicable external operating experience to affected internal stakeholders nor did they conduct self-assessments of sufficient depth that were comprehensive, appropriately objective and self-critical such that the 2006 Unit 2 exam compromise issues were either avoided altogether or at least identified and corrected by Constellation prior to the start of this inspection.Enforcement. 10 CFR 55.49, requires, in part, that, "...licensees shall not engage in anyactivity that compromises the integrity of any application, test, or examination required by this part. The integrity of a test or examination is considered compromised if any activity, regardless of intent, affected, or, but for detection, would have affected the equitable and consistent administration of the test or exam." Contrary to this requirement, the 2006 Unit 2 annual operating tests were compromised since the process used to validate the simulator exam scenarios resulted in licensed operators being knowledgeable of a significant portion of the test prior to its administration.(NCV 05000410/2006011-02, Failure to Ensure Integrity of Unit 2 Examinations andTests)3.Unit 1 Crew Failure Rate on the Dynamic Simulator Portion of the Annual OperatingExaminationsIntroduction. A finding of very low safety significance (Green) was identified at Unit 1,based on two of six crews failing their facility-administered annual simulator examinations.Description. During facility-administered annual operating testing of the licensedoperators, licensee training staff evaluated crew performance on simulator exam scenarios using performance standards derived from NUREG-1021, "Operator 10EnclosureLicensing Examination Standards for Power Reactors." Facility results of crewperformance showed that two of the six crews evaluated (33%) did not pass their simulator exams. The failures are documented in licensee-initiated Condition Report CR 2006-5797, which resulted in Constellation conducting a Category I Root Cause

Analysis.

Constellation's root cause analysis report stated, "The number of individual and crew failures could be indicative of programmatic weaknesses that if unresolved, could affect operator performance on shift, ... 9 of 14 individuals failing the annualoperating exam had been noted as needing improvement in the same areas as on the annual exam (within the last 2 years). 3 of 4 crews failing the annual exam failed a recent evaluated scenario (in 2006) and all 4 crews had failed a scenario in the last 2 years. Ops Management was not fully aware of these performance weaknesses. Other than documentation of remediation for failures, no other documentation was found as described performance improvement plans for individuals noted as needing improvement as required by GAI-OPS-13." GAI-OPS-13, Attachment 1.2, states that,

"...a score of one or two in any competency area or on any event or evolution requiresdevelopment of a plan for improving performance." NRC inspectors observed the administration of the simulator exam scenario evaluations for all six crews and also observed the retest of one of the remediated crews that failed their exam during a previous week.Analysis. A performance deficiency (PD) was identified in that the Systems Approach toTraining (SAT) feedback mechanism standards associated with the Nine Mile Point LORT program were not utilized. Specifically, individual and crew weaknesses were not appropriately identified, evaluated and corrective actions taken. In addition, corrective actions taken for previously identified individual and crew weaknesses were not fully effective (i.e., a Category 1 CR written in 2004 to document a green finding from crew failures on an annual exam). As a result, two of six licensed operator crews demonstrated knowledge and ability weaknesses resulting in less than adequate performance on an NRC required requalification test administered by the licensee.

Traditional enforcement does not apply because the issue did not have any actual safety consequence or potential for affecting the NRC's regulatory function and was not the result of any willful violation of NRC requirements or licensee procedures. This finding was more than minor because it was associated with the Human Performance attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the combined objective of: limiting the likelihood of; ensuring the availability and reliability of mitigating systems to respond to; and providing reasonable assurance that physical barriers protect the public from radio nuclide releases caused by, initiating events. Specifically, the finding reflected the potential inability of the crews to take appropriate safety-related actions in response to actual abnormal or emergency conditions while they were on-shift prior to the requalification testing.Since this is a more than minor requalification training issue, the risk importanceassociated with the number of crews failing the annual operating tests is provided in Appendix I of the SDP. The Simulator Operational Evaluation Matrix was entered using the number of crews that took the simulator test, six, and the number of crews with less than adequate performance, two. Based on these numbers, the finding was characterized by the SDP as having very low safety significance (20 - 34% failure rate),

11Enclosureor Green. The finding is of very low safety significance because the failures occurredduring annual testing of the operators on the simulator, because there were no actual consequences to the failures, because the crews were removed from watch standing duties, retrained, and re-evaluated before they were authorized to return to control room watches, and because the crew failure rate for the 2005 Unit 1 Annual Operating Exams was less than 20%.

Enforcement.

NRC regulations require that licensed operators pass an annualoperating test; the regulations do not specify pass/fail rates. When a failure occurs, requirements are met by restricting the operator from licensed duties until the operator has been retrained and successfully retested, steps which licensee staff completed.

Therefore, no violation of regulatory requirements occurred. Crew performance on the 2006 annual operating exams has been entered into the corrective action program (CAP) as CR 2006-5797, and Constellation performed a level 1 root cause analysis ofthese crew failures. (FIN 05000220/2006011-03, Unit 1 Crew Failure Rate on theDynamic Simulator Portion of the Annual Operating Examinations)4.Unit 2 Crew Failure Rate on the Dynamic Simulator Portion of the Annual OperatingExaminationsIntroduction. A finding of very low safety significance (Green) was identified at Unit 2,based on two of six crews failing their facility-administered annual simulator examinations.Description. During facility-administered annual operating testing of the licensedoperators, licensee training staff evaluated crew performance on simulator exam scenarios using performance standards derived from NUREG-1021, "Operator Licensing Examination Standards for Power Reactors." Facility results of crew performance showed that two of the six crews evaluated (33%) did not pass their simulator exams. The failures are documented in licensee-initiated Condition Report CR 2006-5797, which resulted in Constellation conducting a Category I Root Cause

Analysis.

Constellation's root cause analysis report stated, "The number of individual and crew failures could be indicative of a programmatic weaknesses that if unresolved, could affect operator performance on shift, ... 9 of 14 individuals failing the annualoperating exam had been noted as needing improvement in the same areas as on the annual exam (within the last 2 years). 3 of 4 crews failing the annual exam failed a recent evaluated scenario (in 2006) and all 4 crews had failed a scenario in the last 2 years. Ops Management was not fully aware of these performance weaknesses. Other than documentation of remediation for failures, no other documentation was found as described performance improvement plans for individuals noted as needing improvement as required by GAI-OPS-13." GAI-OPS-13, Attachment 1.2, states that,

"...a score of one or two in any competency area or on any event or evolution requiresdevelopment of a plan for improving performance." NRC inspectors observed the administration of the simulator exam scenario evaluations for two of six crews and also observed the retest of one of the remediated crews that failed their exam during a previous week.

12EnclosureAnalysis. A performance deficiency (PD) was identified in that the Systems Approach toTraining (SAT) feedback mechanism standards associated with the Nine Mile Point LORT program were not utilized. Specifically, individual and crew weaknesses were not appropriately identified, evaluated and corrective actions taken. In addition, corrective actions taken for previously identified individual and crew weaknesses were not fully effective (i.e., a Category 1 CR written in 2004 to document a green finding from crew failures on an annual exam). As a result, two of six licensed operator crews demonstrated knowledge and ability weaknesses resulting in less than adequate performance on an NRC required requalification test administered by the licensee.

Traditional enforcement does not apply because the issue did not have any actual safety consequence or potential for affecting the NRC's regulatory function and was not the result of any willful violation of NRC requirements or licensee procedures. This finding was more than minor because it was associated with the Human Performance attribute of the Initiating Events, Mitigation Systems, and Barrier Integrity cornerstones and affected the combined objective of: limiting the likelihood of; ensuring the availability and reliability of mitigating systems to respond to; and providing reasonable assurance that physical barriers protect the public from radio nuclide releases caused by, initiating events. Specifically, the finding reflected the potential inability of the crews to take appropriate safety-related actions in response to actual abnormal or emergency conditions while they were on-shift prior to the requalification testing.Since this is a more than minor requalification training issue, the risk importanceassociated with the number of crews failing the annual operating tests is provided in Appendix I of the SDP. The Simulator Operational Evaluation Matrix was entered using the number of crews that took the simulator test, six, and the number of crews with less than adequate performance, two. Based on these numbers, the finding was characterized by the SDP as having very low safety significance (20 - 34% failure rate),

or Green. The finding is of very low safety significance because the failures occurred during annual testing of the operators on the simulator, because there were no actual consequences to the failures, because the crews were removed from watch standing duties, retrained, and re-evaluated before they were authorized to return to control room watches, and because the crew failure rate for the 2005 Unit 2 Annual Operating Exams was less than 20%.

Enforcement.

NRC regulations require that licensed operators pass an annualoperating test; the regulations do not specify pass/fail rates. When a failure occurs, requirements are met by restricting the operator from licensed duties until the operator has been retrained and successfully retested, steps which licensee staff completed.

Therefore, no violation of regulatory requirements occurred. Crew performance on the 2006 annual operating exams has been entered into the corrective action program (CAP) as CR 2006-5797, and Constellation performed a level 1 root cause analysis ofthese crew failures. (FIN 05000410/2006011-04, Unit 2 Crew Failure Rate on theDynamic Simulator Portion of the Annual Operating Examinations)4.OTHER ACTIVITIES (OA)13Enclosure4OA5 Other1.Acceptability or Suitability of Nine Mile Point Unit 1 and Unit 2 Simulator Scenario-Based-Tests (SBTs) For Meeting ANSI/ANS-3.5-1998 Performance Testing Criteria The inspectors reviewed actions taken by Constellation since this item was openedduring a 2004 Licensed Operator Requalification Program inspection and determined that this item will remain open pending further NRC review (i.e., the NRC has not reached final resolution with the industry regarding an acceptable level of testdocumentation to support this approach).

(URI 05000220&410/2004005-03,Acceptability or Suitability of Nine Mile Point Unit 1 and Unit 2 Simulator Scenario-Based-Tests (SBTs) For Meeting ANSI/ANS-3.5-1998 Performance Testing Criteria)4OA6Meetings, including ExitThe lead inspector and the NRC Region I Operations Branch Chief presented theinspection results to members of licensee management team in an onsite meeting at the conclusion of the inspection on January 18, 2007.

No materials reviewed were identified by the licensee as proprietary.

A-1AttachmentAttachmentATTACHMENT

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

T. O'Connor, Site Vice President/Plant General Manager
M. Schimmel, Plant General Manager
N. Conicella, Operations Manager
T. Shortell, Training Manager
M. Miller, Director Licensing
B. Brown, General Superintendent Operations Training
J. Krakuzeski, Unit 1 Operations Supervisor
R. Slade, Unit 2 Operations Supervisor
D. Newman, Supervisor Operations Requal
M. McCrobie, Simulator Support Supervisor
M. Peterson, U1 Simulator Test Specialist
E. Benedicto, U1 Simulator Software Engineer
D. Kelly, Requal Exam Developer
G. Bobka, Operations Training
W. Coppom, Operations Training

NRC Personnel

L. Cline, Senior Resident Inspector
E. Knutson, Resident Inspector
J. Caruso, Senior Operations Examiner/Inspector
P. Presby, Operations Examiner/Inspector
R. McKinley, Operations Examiner/Inspector (UI)
J. Sullivan, Operations Examiner/Inspector (UI)

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened05000220/2006011-01AVFailure to Ensure Integrity of Unit 1 Examinations andTests (Section 1R11.1)

05000410/2006011-02NCVFailure to Ensure Integrity of Unit 2 Examinations andTests (Section 1R11.2)
05000220/2006011-03FINUnit 1 Crew Failure Rate on the Dynamic Simulator Portionof the Annual Operating Examinations (Section 1R11.3)

A-2AttachmentAttachment05000410/2006011-04FINUnit 2 Crew Failure Rate on the Dynamic Simulator Portionof the Annual Operating Examinations (Section 1R11.4)

Discussed

05000220&410/2004005-03URIAcceptability or Suitability of Nine Mile Point Unit 1 andUnit 2 Simulator Scenario-Based-Tests (SBTs) For

Meeting ANSI/ANS-3.5-1998 Performance Testing Criteria

LIST OF DOCUMENTS REVIEWED

Procedures:TAP-TQS-04 NMP Examination Standard Rev. 07NTP-TQS-102 Licensed Operator Requalification Training Rev. 35

NTP-TQS-400 Instructions for Completing and Processing NRC Forms 396 and 398 Rev. 18
S-FFD-16 Fitness for Duty Procedure Rev. 04
S-ODP-TQS-0101 Administrative Controls for Maintaining Active License Status at NMP Rev.
GAI-OPS-13 Operations Score Card Program Rev. 03
NMP-TR-1.01-10 Analysis Phase Activities Rev. 0
NMP-TR-1.01-20 Design Phase Activities Rev. 0
NMP-TR-1.01-30 Development Phase Activities Rev. 0
NMP-TR-1.01-40 Implementation Phase Activities Rev. 0
NMP-TR-1.01-50 Evaluation Phase Activities Rev. 0
NMP-TR-1.01-60 Simulator Operation & Testing Rev. 0
NMP-TR-1.01-70 Training Administration Rev. 0Other:CR-NM-2006-4808Category I Root Cause Analysis (CR-NM-2006-4808), "Annual Licensed Operator Requalification Exam Compromise"
NMP1 2006 Biennial Exam Sample Plan
NMP1 Biennial Schedule 05/06 Rev.1
NMP1 Independent Self-Assessment Report, Assessment #:
FSA-2006-43 Scenarios:*O1-OPS-009-1-DY-71 rev. 0 AWTS w/ Main Condenser
  • O1-OPS-009-1-DY-25 rev. 6 Steam Leak in Drywell w/ blowdown
  • O1-OPS-009-1-DY-39 rev. 6 Steam Leak in Drywell
A-3AttachmentAttachment*O1-OPS-009-1-DY-48 rev. 4 AWTS w/ Main Condenser*O1-OPS-009-1-DY-50 rev. 2 AWTS w/ Main Condenser and Torus Leak
  • O1-OPS-009-1-DY-53 rev. 3 Steam Leak in Drywell
Open Simulator Deficiency Reports (DRs)Scheduled Simulator Enhancements Simulator Training Load Acceptance Reports- June to August 2006

- Dec. 2005 to March 2006

- Sept. to Dec. 2005

- July to Sept. 2005Simulator Exceptions List Simulator Four Year Test Schedule Simulator Configuration Control Board (SCCB) Meeting Minutes:- October 19, 2005

- August 4, 2006

- July 14, 2006Simulator Documents related to Jan 2004 Emer Cooling Test (NCV05000220/2004005-02)- DR 3531

- DR 3538

- Upgrade

DR 802005 Simulator Model Test, ANSI 3.5 Appendix "B" B1.2(3) Simultaneous Closure of All MSIVsSimulator Deficiency Reports-
DR 3884, Recirc Pump Metering

-

DR 3799, Offgas Controller

-

DR 3798, RWCU Conductivity

-

DR 3797, Indicator Should Read Downscale

-

DR 3789, Safety Valve Outlet High Temperature

-

DR 3782, Pressure Oscillation with TC05 Initiated

-

DR 3760, Malfunctions FW29A&B Do Not Work

- Upgrade

DR 165, Change Sim Status Hi Press SettingCondition Reports Related to Simulator-
CR-NM-2005-542, NRC Identified Green NCV

-

CR-NM-2005-615, NRC Identified URI on Suitability of SBTsSimulator Scenario Based Tests for Cycle C09 and Cycle 10 (2006)
Simulator vs. Plant Comparison for Stuck Open ERV
Simulator vs. Plant Comparison for 8/3/04 Feedwater Spiking, Manual Scram
2005 Simulator Steady State Comparisons at 40%, 75% and 100%
Retrieved from "https://kanterella.com/w/index.php?title=IR_05000220/2006011&oldid=242143"