ML20086Q196
| ML20086Q196 | |
| Person / Time | |
|---|---|
| Site: | Cooper  |
| Issue date: | 11/01/1991 |
| From: | NEBRASKA PUBLIC POWER DISTRICT |
| To: | |
| Shared Package | |
| ML20086Q188 | List: |
| References | |
| NUDOCS 9112300051 | |
| Download: ML20086Q196 (20) | |
Text
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ENERGENCY PREPAREDNESS A.SSESSMENT REPORT H
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l NEBRASKA PUBLIC POWER DISTRICT l COOPER NUCLEAR STATION l
Brownville, Nebraska l
November 1,1991 1
R kDohK 05b h98 G PDR
TABLE OF CONTENTS Assessment Report Submittal i Assessment Activities Summary 1 Facts 4 Conclusions 12 Recommendations 16 4
e Emergency Preparedness h(%
Assessment Report i
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ASSESSMENT REPORT SUBMITTAL This report is respectfully submitted to the Division Manager-Nelear Support by the following:
R. J. Bruno. Exitech Cort oration !, ,//#/
E. ht Mace #
G. E. Sniith
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D. C. Sh rade r _
[ j K. M. Krumland M. #~
- 11. J. Gleason, Exitech Corporation / /-@pt, , eGM r/
The strengths, weaknesses, and recommendations represent the consen.us views of this team.
Although, during our deliberations, differing opinions and views were expressed, no ininority opinions were lef t unresolved and no disagreements remain. We are able to discuss the report in detail at your convenience.
Emergency Preparedness Assessment Report il
- 1. ASSESSMENT ACTIVITIES
SUMMARY
As a result of weaknesses identified by the NRC in command and control functions in the Control Room (CR) and Technical Support (TSC) Center during the Emergency Preparedness Exercise conducted on July 24,1991, a Self Assessment Team was appointed by the Division Manager of Nuclear Support. The Self Assessment Team was assigned by the Division Manager of Nuclear Support to review the circumstances contributing to the identified weaknesses; to assess the Control Room and Technical Support Center emergency organizations; to assess the command and control arrangements;and, to assess the overall effectiveness of these emergency response facilities and their staffing.
The Self Assessment Team met four times from October 7 through November 1,1991. The assessment was guided by the Nuclear Power Group Self Assessment Program and a 'f ault tree' technique was employed to structure the assessment, generate questions for interviews, and ensure that both issues specific to the July 24 Exercise and more general systematic issues were considered.
The Team began its work by developing a working defin tion of " command and control."
Command and control was considered to be r complex interaction between ERT managers, key players, and the remaining personnel involved in the ERO. As such, in its highest tier, it involves management, organization, communication, and facilities. The Team sought to obtain information about these aspects of the ERO performance in the current exercise. Additional information was obtained by reviewing the ERO performance for other drills condarted in 1991. The primary method for gathering data was interviews, although hard records were reviewed in some cases.
For the development of the fault tree, the Emergency Response Organization was considered to be effective in its conduct of Emergency Plan Activities when appropriate commsnd and controlis exercised. For this to occur, personnelin the ERO must bo rr: pared for their duties by appropriate training and participation in drills and exercises; arr.ergency procedures must provide clear guidance and direction; and the ERO must be well su sctured, with duties clearly designated and effective commur.ication naths established. Once prepared, personnel must execute their respansibilities we'l. This execution is suppn ted by accurate and timely technicel information, resources, and, of course, the performance of each individual in the ERO.
The Self-Assessment Team conducted interviews with twenty five personnel, reviewed records of past exercises and drills and applicable Emergency Plan procedures, and discussed at le.ap h the conclusions and recommendations contained within this report. The individuals interviewed represent players in the recent exercise, personnel who developed the scenario and controlled and evaluated the exercise, training personnel, the former NRC Senior Resident Inspector, and others as shown in the Table below.
Emergency Preparedness Assessment Report 1
4 9 PERSONNEL INTERVIEWED IN TIIE SELF-ASSESSMENT l
Individual Position Emergency Plan Position I Dob Beilke Radiological Support Manager (Acting) Radiological Controls Manager Rick Bennett Senior Resident inspector (USNRC) NRC Player Mark Dergmeter Control Room Supervisor Control Room Supervisor Bob Black Operations Supervisor Control Room Director Jim Dutton Nuclear Training Manager Mike Estes Nuclear Management Trainee Controller / Evaluator Jim Plaherty Engineering Manager Engineering Coordinator Richard Gibson Audit and Procurement QA Supervisor QA Evaluator Mark Gillan Nuclear Training Supervisor
, Bob Hayden Emergency Preparedness Coordinator Controller / Evaluator Ed Jackson SRO/RO Instructor Control Room Tech Communicator Steven Jobe Simulator Supervisor Mark h aul Shif t Supervisor Shif t Supervisor George Ke:ner Instructor Emergency Planning Coordinator Mike Krumland Emergency Preparedness Supervisor Dave Kuser Shif t Supervisor EOF Operations EOP Advisor Gene Mace Senior Manager of Staff Support TSC Director John Meucham Division Manager of Nuclear Emergency Director Operations Leo Parks Technical Systems Administrator SPDS/ Computer Applications
' Jim Salisbury Lead Performance Engineer Shif t Technical Advisor Vern Stairs Assistant Operations Manap,er _ TSC Operations EOP Advisor Ken Talbott Senior Staff Review Group Specia.ist Controller / Evaluator Mike Unruh Maintenance Manager Maintenance OSC Coordinator Dave Whittnan Division Manager of Nuclear Support Designated Spokesperson l
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These interviews and other efforts provided the Self Anessment Team with raw data in the form of observations, opinions, conclusions, and recorr.mendations. In the deliberations that followed, the Team distilled a set of facts that were grouped into eight categories for analysis:
Management / Leadership / Decision Making: Communications; Facilities; Organization: NRC Interf ace; Training; Scenario Preparation, Conduct and Evaluation;and,Drillsmanship. Other facts, undoubtedly, could also have been stated, but of the facts found by this Team, they were felt to be either non contributory or redundant, and were, thus, eliminated. These facts represent the best judgement of the Self* Assessment Team and are not as easily discernable or objective as, for example, facts that can be obtained from control room logs, charts, computer history files, and to on. However,in the opinion of the Seli Assessment Team they are no less true than these more objective sources.
The Conclusions were derived from the facts. In the analysis, both strengths and weaknesses were found. Obvious strengths exist in the experience of NPPD personnel and the selection of individuals to fill key positions in the Emergency Response Organization. Ilowever, given the constraints of time and the nature of our assignment, the Self Assessment Team dedicated its time to identifying weaknesses and proposing effective corrective actions in the form of recommendations.
The Recommendations are designed to improve the Emergency Response Organization at Cooper Nuclear Station. These Recommendations are um limited to the Emergency Planning Organization and cannot be implemented by Emergency Planning alone. Rather, they will require a team ef fort with Emergency Planning. Training, Nuclear Operations, and others, to achieve full implementation and meet the intent of the Recon mendations. It should be understood that these are recommendations for improvement and the Self Assessment Team agrees with the t*RC judgement that the "... emergency preparedness program and staff were prepared to protect the health and safety of the public." The weaknesses identified were primari!y consequences of communication, organization, and training problems. Difficulties with drilismanship, f acilities, control of the NRC/NPPD interf ace, and exercise conduct and exercise evaluation exacerbated these weaknesses and made them more clear to the exercise evaluators.
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- 2. FACTS Management /Leadersnip/ Decision Making M1 The TSC Director was not kept appraised of the status of a re entry team dispatched to obtain a post accident sample, or its lack af completion.
M2 TSC status boards were not ktpt cun 7nt throughout the exercise.
M* 3 Command and control problems were not identified in laternal NPPD evaluations in the past and were identified only as an observation in the most recent exercise.
M4 The command and control aspects of the ERO performance have not been formally evaluated in the past.
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- C0intillinications C1 The Control Room Communicator talks with four others at the same time on the same common line utilizing restricting communications hardware.
C2 The Control Room Director talks directly to the if P/ Chemistry Coordinater in the TSC for dispatch of Control Room personnel during the emergency.
C3 The Control Room Communicator asked operators for detailed information about the performance of steps in the EOPs for the Operations EOP Advisors in the TSC and EOF.
C4 The STA in the Control Room was used to acquire plant information by the Engineering Coordinator in the TSC.
C5 There are at least two communication paths from the Control Room to the TSC Director that are redundant and potentially confusing.
C-6 Communication between the Shift Supervisor and STA was minimal.
C7 Conflicung information was received in the TSC about the Start up Transformer, 3 Emergency Preparedness Assessment Report 5
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Facilities F1 The simulator is not specifically designed to be used in an emergency exercise.
F Some almulator problems occurred during the conduct of the exercise.
F3 PMIS data would be available in the TSC snd EOF during an actual event. PMIS data is presently not simulated in the TSC or EOF termina!s in drills or exercises.
F-4 Budgets are not specifically established to update and maintain the simulator to support Emergency Plan exercises. .57.1 Emergency Preparedness Assessment Report 6 h($
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Organization O1 The Operations EOP Advisor in the TSC was not sure of what he was supposed to do- keep up on EOPs or QC eof s?
O2 The STA was on the phone too much and lost track of the status of the plant.
O3 The Op'erations EOP Advisor in the TSC couldn't keep up with EOPs and got lost.
O4 The availability and use of relief crew was viewed as a strength.
O5 Very little advice was provided to the Shift Supervisor by the STA.
O6 The Control Room Communicator felt that a lot of people from the TSC/ EOF tried to "second guess
- Control Room Operator actions regarding EOP implementation.
O7 TL Operations EOP Advisor in the EOF was performing a *QC' check on the implet.ientation of the EOPs in the Control Room.
OS The duties of the Control Room Director are not clearly defined.
O9 The command and control duties of ERF management personnel are not defined.
O 10 The Control Room Communicator had to answer questions from the TSC/ EOF that dealt with EOPs.
O-11 There were no significant changes to the EPIPs within the last 12 months.
O 12 The EPIPs do not recognize the Operations EOP Advisors in either the TSC or EOF.
O 13 Personnel accountability is automatically initiated at the Alert Classification.
There is no external requirement for this.
O 14 TSC en'ineers g were working on a list of things they were trying to assess for fixes for which they needed plant data (obtained from the STAL O-15 The STA was maintaining a list of things the TSC was working on.
p-16 The most senior people in the NPPD organization are selected for roles in the ERO.
0 17 Thirty seven (37) re entry teams were dispatched by the TSC during the 1991 Exercise.
l O 18 The Maintenance OSC Coordinator performed re entry assignments, re entry team briefings, re entry team debriefings, and OSC Coordination along with staf f responsibilities.
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NRC Interface I-l The NRC exercise players requested a lot of information during the exercise.
12 The NRC evaluator in the simulator was not appraised of the !!mitations of the simulator.
13, The NRC Region IV players arrived later than the exercise scenario expected.
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4 Training T 1- The Emergency Plan initial and continuing training programs are not performance based.
T 2. ERF management personnel are not trained on all technical, administrative, and -
command and control aspects of their emergency response duties.
T3 ERF management is not tra'ned on RTM 91.
T-4 The training provided to personnelin the ERO is essentially a review of selected Emergency Procedures f911 owed by a written test.
T-5 Alternates are trained but are not usually rotated into ERO positions for graded exercises.:
T-6 Alternates participate in some mini-drills and dress rehearsals as players.
T-7 Neither initial nor continuing training for'ERO personnel is implemented via a systematic approach.
T-8 Command and control expectations of management are not clear to key players in the ERO.-
T-9 Personnelin key positions are selected to fill their ERO positions without an evaluation of their command and control abilities,
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y Scenario Preparation, Conduct, and Evaluation S1 Only one comment from 1991 drill evaluations related to personnel performance.
S2 There is a gap between critique items and feedback to the evaluators of its resolution.
S3 Evaluators have not formally considered command / control areas in drills.
S4 Simulator personnel were not consulted during the preparation of the exercise scenario.
S5 Station Operators were dispatched to areas without a controller at times.
S6 EP requested about five (5) people to support the team for the 1991 scenario. They received the aid of only three (3).
S-7 There was no senior manager on the scenario development team.
S-8 There were not enough controllers / observers for sll of the re entry teams deployed during the exercise.
S-9 There was no central control station for the evaluation team (control cell).
S 10 There were fif ty six (56) objectives identified for the 1991 Emergency Exercise.
More than half of do not contain appropriate evaluation criteria.
S 11 None of the 1991 Emergency Exercise objectives related directly to command and control performance.
S 12 Command and control are not identified specifically in any EP evaluation documents, NRC or otherwise.
S 13 No one was specifically assigned to observe the CRD during the exercise.
S-14 A controller told players something which was broken would not get fixed- prior to attempts to troubleshoot and repair.
S 15 No formal system exists for documenting evaluation of the fif ty six (56) objectives listed in section 2.0 of the exercise manual.
S 16 ERFs requiring activation have EPIPs that provide clear direction (checklists) to key players.
S-17 Drill records for 1991 indicate that most of the evaluation comments are aimed at procedures and equipment and not at the players.
5-18 There are no formal records of who participates in mini drills.
S 19 There is no method of evaluating individual position performance during scheduled minidrills.
Emergency Preparedness Assessment Report 10 hh
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l Drilismanship D1 Af ter critical tasks are completed, an " easing off* occurs in the TSC.
D2 The Radiatic.n Control Manager actively uses the controllers and observers, etc.,in the emergency exercise.
D3 NRC evaluators did not hear all of the appropriate communication between players and controllers or between players and other players.
D4 Several key managers feel that NPPD personnel are generally poor players.
D5 All players are Invited to the pre exercise briefing which includes directions on
" playing," but attendance is not mandatory.
q D6 Briefings in the contrcl room were few.
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- 3. CONCLUSIONS CN 1 Staff meetings in the TSC area are conducted during the routine management of TSC tasks.
Accordingly, some aspects of command and control are not always exercised or exhibited.
CN 2 The STA and Control Room Director were unable to fulfill their designated control room responsibilities because they were involved with extensive communications outside the control room.
CN 3 Personnel in the TSC and EOF tend to request extensive information from personnel in the Control Room, much of which is not required for the mitigation of the emergency events.
CN 4 The assignment of duties including management's expectations for key ERF personnel and their command and control responsibilities is unclear.
CN 5 The Maintenance OSC Coordinator is overloaded in the performance of his duties.
CN 6 The lack of au' lability of PMIS data to the ERFs contributed to the overload of communication links and difficulties in command and control.
CN 7 The lack of a systematic, performance based training program for ERF personnel contributed to deficiencies in command and control.
CN-8 NPib personnel need improvement in their 'drillsmanship* abilities to better demonstrate command and control and other knowledge and skills.
CN 9 The internal evaluations of past exercises and drills have been weak in that they have not evaluated personnel performance or command and control in suf ficient detail.
CN 10 The lack of rotation of personnel qualified for key ERF positions in major drills, dress rehearsals, or exercises contributes to command and control problems.
CNil The TSC, CR, and EOF functions are not clearly separated, and has caused a proliferation of inf ormation exchange. much of which is unnecessary.
CN 12 The exercise controllers were not fully effective in ensuring exercise information was exchanged with the NRC evaluators at appropriate times before and during the exercise.
CN-13 Exercise control is in need of improvement.
C N- 14 Accountability is performed too soon and without sufficient reason and requires the ERO to manage personnel from Emergency Response Centers before it is necessary.
CN15 The Oparations EOP Advisors in the TSC and EOF are not necessary and require unnecessary communications.
CN 16 Re entry of operations personnel on teams from the Control Room contributes to communications problems and is difficult to control.
CN-17 The use of the simulator in the exercise was a benefit, although start up problems v ere encountered.
C N- 18 Communication between Control Room and other Emergency Response Personnel was affected by the NRC player's needs for information.
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FACTS
- CONCLUSIONS MATRIX CN- CN- CN- C N- CN CN- CN- CN CN- CN C N- C N- CN CN- CN- CN- CN- CN-1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 hi ! X X X M2 X M3 X M4 X C1 X X X X C2 X X X X C3 X- X .X X -X C4 X X X C5- X X X X C-6 X X X C7 X X F1 I X F-2 X X X F3 X X X F4 X X O1 X X X O2 X X. X X O-3 X X 04- <
O5 X X X O6 X X X O 7- X X X h O8 X' X X X X O9 X X X X X .
O-10 X X X X Emergency Preparedness Assessment Report 13
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% CN- CN- CN CN- CN- CN- CN- CN- CN- CN- CN- CN CN- CN- Ct' CN- CN CN-a 1- 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 O il O 12 X 0-13 _
X X 4 0-14 X X X X 0-15 X X
!- 0-16 O 17 X O 16 X X 3
I II X X I2 X X X I-3 X X T1 X -X T2 'X X T-3 X X X T4 X X .
- T S X X T7' ;
X X
!. T-8 ~i I X X X X X p- .
T-9 X X S1 X X X S-2 S X X X I
s4 l x S-5 X X X S-6 X t S7 l X I Emergency Preparednee.s hj Assessment Report 14
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CN- C N- CN- C N- C N- CN- CN- C N- CN- C N- C N- C N- CN- CN- CN- CN- CN- CN-1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 S-S X X X X S-9 X X S-10 X S Il X X S-12 X S 13 X X X X S 14 X X 15 X s-P 16
! S 17 X X XyX S 18 X S-19 X X X X X __
l D-1 X X X X D2 X D-3 X X X X D-4 X X X '
D. X D-6 X j X X s
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- 4. RECOMMENDATIONS R1 During the performance of Emergency Plan activities in the TSC, schedule and conduct staff meetings using a prepared agenda in the TSC conference room.
R2 Clarify the responsibilities of en h Emergency Response Facility and ensure each facility is fulfilling its intended purpose.
R-3 Clarify the duties and responsibilities of all key ERF personnel including each ERF C<ector by perfotming a Job Analysis for each key ERF position.
R4 Using the results of the Job Analyses in Recommendation 3, design, develop, and implement initial and continuing training for personnelin the Emergency Response Organization via a systematic approach.
RS Develop and implement a formal exercise evaluation system including documentation methods to be used by evaluators during drills and exercises.
R-6 Establish the role of the simulator in the emergency preparedness drills and exercises and update procedures, f acilitics, and equipment to support that role.
R7 Perform the plant evacuation and accountability as necessary based on safety considerations rather than " automatically
- as is presently done at the Alert classification.
R-8 Require Plant Operators to report to an OSC and control their re entry through the TSC. once plant evacuation and accountability has been initiated.
R-9 Improve the ability of NPPD ERF personnelin their drillsmanship by performing training, demonstrations, and critiques of individual performance on their ability to demonstrate their knowledge and skill.
R-10 Eliminate the Operations EOP Advisors in TSC/ EOF.
R-i l Af ter an engineering analysis of allowable RF power limitations and requirements, obtain wireless headsets for the ERF Con.municators.
R-12 Provide additional support for the Maintenance OSC Coordinator in assist in supervision of ra entry activities and allow him to better discharge his staff responsibilities.
R-13 Develop and implement guidance for exercise control.
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CONCLUSIONS
- RECOMMENDATIONS MATRIX
' R-1 R-2 R-3 R-4 R-5 R-6 R-7 R-8 R9 R-10 R-11 R 12 R 13 CN 1 X CN 2 X X X X CN S X X X X X CN-4 X X X X X CN-5 x X CN-6 X X CN 7 X X X X CN-8 X X CN-9 X X CN-10 X X CN-il X X X CN-12 X CN13 X CN-i4 X X CN-15 X X CN-16 X X CN-17 X j CN-18 d X v-Emergency Preparedness Assessment Report 17 h%
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