ML20247H267

New Hampshire Yankee Performance During & Following Natural Circulation Test of 890622

ML20247H267
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Site:	Seabrook
Issue date:	07/10/1989
From:	PUBLIC SERVICE CO. OF NEW HAMPSHIRE
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OL-1, NUDOCS 8909190261
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IRT E N N N IVENESS ANALYSIS REPORT ,

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, NHY Performance During and Following The l

Natural C.rculation Test of' June 22, 1989 l ISSUED: July 10, 1989 I D

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L- i TABLE OF CONTENTS y

IRT N5Y MANAGBENT EFFECTIVENESS ANALYSIS REPORT 1

, 3 SECTION PAGE 1.0 ' Executive Summary 1 2.0 Analysis and Revie'w 2 A. Command and Control Poliev 2

1. Background and Existing Policy 2

.2 . Application of the Cormand and Control

' Policy- 3-3;--Conclusions 5

4. Command And Control Policy Recommendations 6 B. Procedure Comoliance Policy 7.

1. Background and' Existing Policy 7

2. Application of the Existing Procedure Compliance Policy 8

3. Conclusions 10

4. Procedure Compliance Policy Recommendations 11 C. Post Trio Review Policy 12

1. Background and Existing Policy 12

2. Application of the Post Trip Review Policy 13-

3. Conclusions 24

4. Post Trip Review Policy Recommendations 27 D. Steam Dumo-Valve Incomplete Work Reouest 29

1. Background

2. Conclusions

3. Recommendations

yy TABLE OF CONTENTS

.1; pHY MAHAGBENT EFFECTIVENESS ANALYSIS REPORT i

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ATTACHMENT ' NHY MANAGEMENT EFFECTIVENESS CHRONOLOGY .<

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SECTION PAGE -I l

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Thursday.-June' 22. 1989: 1 l 1219 -- Initiation of Natural Circulation Test J (1-ST-22) 1 j

.--- NKC Communications.To NHY In Main Control Room 1 1 1236 -- Manual Reactor Trip' 3 .

1350 -- VP-NP Communications To President'and CEO, VP-Engineering. Licensing and Quality j Programs 5 1500 - . Post Trip Review Critique In TSC 7 1800 -- NHY Telecon~To NRC Projects Branch Chief 9 i

2315 -- VP-NP Briefing Of President and CEO 14 Friday. June 23. 1989: 15 0730'-- NHY Telecon To NRC Projects Branch Chief 16 1140 -- NHY/NRC Meeting 20 1350 -- NRC/NHY Confirmatory Action Letter Telecon 23 1430 -- NHY Meeting To Plan and Schedule NHY CAL Response Activities 25

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NHY Manamament Effectiveness Analysis Report I

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1.0 Executive Summary. J l

New Hampshire Yankee (NHY) conducted a review and analysis of the policies,

. procedures and implementing actions taken by NHY personnel to assess the adequacy and effectiveness of the NHY Management response during and subsequent to the Natural Circulation Test conducted at Seabrook Station on June 22, 1989. Short and longer term corrective action recommendations have been developed and are presented in this report based on the review and analysis conducted by the NHY Independent Review Team (IRT). a staff group not functionally associated with the NHY groups that conducted the Low Power Test Program.. The scope of the IRT 1 review was specifically focu. sed on, but not Ibnited to three NHY policy areas as they relate to this event: I

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• Command and Control Procedure Compliance Post Trip Review NHY has established written policies and implementing procedures and has  ;

conducted training for NHY personnel as part of the normal administrative process l for providing guidance on the conduct of operations for Seabrook Station. The results of the IRT review and analysis form the basis for recommending enhancements in each policy area. Each of the following analysis and review sections of this report provides a background and summary of the NHY policy in effect at the time of the event, provides a discussion of the application of that policy during and subsequent to the event, provides the IRT management effectiveness analysis conclusions and provides recommended corrective actions for each of the above three policy areas.

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2. 0' Analysis and Review A.- Command and Control Policy

- k 1.. Background and Existina Policy 1j 1

f A series of hierarchical NHY manuals describe the lines of authority I delineating responsibility for command and control at Seabrook Station.

The Seabrook Station Management Manual, Operations Management Manual and Startup Test Program Description provide the guidance applicable to the operation of the. Station and conduct of testing. The. Operations Group is responsible for ensuring the safe operation of Seabrook 'i Station in accordance with regulatory guidance, technical. ,

1 specifications,and approved procedures. NHY uses six shift crews of  ;

1 Operations Group personnel to provide continuous manning of the .

station. Each shift consists of a Shift Superintendent,' Unit Shift j Supervisor, a Supervisory Control Room Operator, Control Room Operator _j and Auxiliary Operators. The Operations Management Manual details the responsibilities, qualifications, authority and source of direction for each shift position. Each licensed operator retains the authority to either order the shutdown or to shutdown the reactor. The Unit Shift Supervisor is the shift position normally responsible for maintaining a comprehensive perspective on operational conditions and in an emergency i

or transient situation becomes the sole authority in charge of the  ;

Control Rocm unless relieved of that duty.

The Startup Test Program Description describes the organization, responsibilities and procedures which ensure that components, structures and systems are tested to verify that they function as designed. The Startup Test organization is structured to provide parallel counterpart positions to the Operations Group. Under the overall direction of the Startup Manager, each Startup test shift is comprised of a Shift Test Director, Test Director and Test Engineers.

These personnel are trained and qualified to perform assigned responsibilities, but are not licensed operators.

L The Startup Test Program consists of specific individual tests performed during and subsequent to initial fuel loading. These tests 2

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vseify ths propar'dosign of.ths roactor cora and tha dynzmic characteristics of,the plant during both normal and anticipated abnormal operating conditions at power levels up to and' including 100%

' design reactor power. Individual test procedures for Low Power Testing were written by the Startup Test organization, were reviewed and approved by.the Startup organization and the Station Operation Review Committee. In addition, all FSAR listed Startup Test procedures were reviewed by the NRC and selected Startup Test procedures including L 1-ST-22 'were reviewed by the NSSS supplier (Westinghouse). The plant operation for each test was done by the Operations Group with technical assistance and direction provided by the Startup Test organization to ensure'the technical adequacy and satisfaction of test parameters. The Startup Test organization retains the authority to interrupt or terminate tests based on the conduct of the test or plant parameters.

The authority and responsibility for overall plant conditions, Including the conduct of tests, and reactor shutdown is vested only in licensed operators.. The Operations and Startup Test organizations developed a working relationship, policy and practice whereby Startup personnel. provide the technical direction for conducting the test and Operations personnel implement the test.

2. ADD 11 cation of the Command and Control Policy

-The conduct of Startup Test-22 Natural Circulation, was initiated using the standard practice where the Startup Test Director briefed the Operations shift on the conduct of the test, expected plant performance and limiting conditions for the test, The Test Director provided copies of Attachment 9.3 to 1-ST-22. Expected Plant Response and Manual Trip Criteria (which included pressurizer level less than 172), to the Shift Superintendent, Unit Shift Supervisor (USS), and licensed board operators. During the actual conduct of the test the following events occurred (a) One of two primary board operators focused primarily on pressurizer level, letdown and charging. This operator monitored and audibly informed the USS of pressurizer levels several times throughout the test.

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(b) The Unit Shift Supervisor was cognizant of pressurizer level throughout the test. The USS conferred with the primary side board operator several times and informed the Test Director that pressurizer level was approaching and later was below 17Z. The Test Director did not subsequently recall receiving this information.

(c) A NRC inspector informed the Startup Manager that pressurizer level was below 172.

(d) A NRC inspector informed the Test Director (second NRC to NHY.

notification) that pressurizer level was below 17%. The Test l Director informed the USS. The USS acknowledged this communication.

(e) Two NRC inspectors subsequently informed the Assistant Operations.

Manager (AOM), (third NRC to NHY notification) that pressurizer level was below 17%. The AOM confirmed the test trip criteria with the Test Director and that the pressurizer level status information had been conveyed to the USS. The AOM began to more fully assess plant status to determine the need to personally intercede with the USS actions being taken. Prior to completing the assessment the USS had directed the second of the two primary side board operators to shut down the reactor.

(f) After tripping the reactor, the operators entered their post trip emergency procedures and brought the plant to the HOT STANDBY condition.

The following factors influenced the application of the Command and

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Control policy. The Operations Manager and Assistant Operations Manager were aware that the test procedure contained trip criteria but were not aware of the specific trip criteria (172 pressurizer level) cited in the startup procedure. The Shift Test Director and Test Director were involved in detailed in-process data gathering and i analysis to ensure that certain test parameters were maintained. The Shift Superintendent heard the report that letdown had isolated 4

.(prsssurizsr.laval less then 172) but.continusd with his'parsonal

. efforts;to identify the cause of the unexpected cooldown. He was -

focused'on the Tavg trend and on the condenser steam dump valve performance. The Shift Superintendent was not aware of the communications between th'e NRC, Test Director.and Unit Shift Supervisor and was not aware of: their substance.

Due to the. unique nature of this test and a FSAR commitment for operator training a total of fifty-seven people were in the Control. l; Room to conduct or observe the test. 'The Contro1~ Board was manned with supplemental primary and secondary side operators. Three additional.

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full shift crews.of operators were also present to' observe the test as part of an FSAR training commitment.

Summary: '6 - NHY Management 15 - Operators (On-Shift) j 8 - Test Personnel (On-Shift)  ;

3 - NRC  !

16 - Operators (Observation training to satisfy FSAR Consnitment) I 4'- Training Department Personnel 3 - QA/QC 1 - ISEG ,

_J,- SAT 57 - TOTAL

3. Conclusions 1

Analysis and comparison of the existing Command and Control Policy  !

with the events of June 22, 1989 provides the basis for the following  ;

conclusions:

(a) Operations Department Command and Control Policy functioned as designed if consideration is strictly limited to the Limiting Conditions for Operation sections of Seabrook Station Technical Specifications and the operations Departgant Operating procedures which provide'the bounding criteria for safe plant operation and transient recovery. However, the Operations Command and Control Policy did not function as designed with respect to adherence to 5

1 the Sanbrook Station Administrative Controls, Policy end Guidance associated with procedure compliance.

a (b) The' members of the assigned Operations shift crew should have exercised their authority to either direct a shutdown or to shutdown the reactor when the pressurizer level fell below the 17%

test specified. trip criteria.

(c) The Startup Test Director should have strongly and immediately recommended shutting the reactor down, in a clear precise manner to the Operations individual in command (USS), when the test trip criteria was reached. ]

(d) The Startup Manager and Test Director should have been immediately responsive to the information provided by the NRC inspector.

(e) The addition of supplemental board operators could have been more fully supported through more specific training and simulator exercises designed to practice command and control functions i unique to the 1-ST-22 test and the actual crew assigned to conduct the test.

4. Command and Contro-1 Policy Recommendations The following corrective actions are recommended:

(a) Revise the existing Command and Control policy to clarify the integration, participation and input of the Startup Test organization and other groups that interact with the shift operators concerning station operations.

(b) Revise the existing Command and Control Policy to delineate responsibility and authority when supplemental operators are assigned on shift.

(c) Revise the existing Command and Control Policy to specifically encourage non-shift, licensed Operations personnel to provide 6

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, points.:of cicrification: or information whsn an assignsd oporator's actions appear to be' inappropriate or not. understood by the observer.

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B. Procedure Como11ance Poliev- I d

1.- Background and Existina Policy

.The Seabrook Station Technical Specifications NHY Operational Quality-Assurance Program ,Seabrook Station Management Manual and Operations

. Management Manual collectively delineate.the criteria for: issuing approved procedures and assuring that implementing activities are-

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conducted.using' approved procedures. In addition, the~Seabrook Station- -i Management' Manual (Chapter 2 Section 1.5) and Operations Management I C . Manual'(Chapter 3. Section 2) provide specific guidance'regarding' ' l1 adherence to procedures. The Operations Management Manual provides , j instructions'for Operations procedures including the following: ~ j l

" Plant operation should be conducted in accordance with applicable procedures. -If procedures are deficient, a procedure change l should be initiated. .An. exception to this policy is that.in-emergency conditions operators may take whatever action is necessary to place the. plant in a safe _ condition, and to protect equipment, personnel andlpublic safety without first initiating a i

procedure change." i The recent Self Assessment Team review of existing Operations  !

I procedures indicates that procedure revisions are approved and issued per existing administrative guidance. Changes to procedures are prepared and issued to correct identified procedural deficiencies. A further review of recent (1989) Station Information Reports indicates that the Operations Group has experienced two incidents where additional-policy clarification (valve and component position verification) in implementing procedures required incorporation.

Corrective actions to incorporate the enhanced policy and provide initial anc ntinuing training were taken.

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NHY p2rsonn21 racsntly~ettsndid o'rsgicn21 forum whsra ths NRC discussed adherenc'e.to procedures as a key industry factor for necessary pe'rformance improvements More recently (March), the Operations Group, Station Management and Self Assessment Team each. proposed the formation and staffing of a

.1 group of! personnel within the Operations Group specifically dedicated to perform periodic procedure reviews, raducing the number of. approved changes not incorporated in procedure revisions, procedure preparation, and a one' time special consistency review'for all Operations procedures. The March proposals also recommended the addition of one senior level operator position on each shift, who in turn would be l assigned responsibilities designed to further relieve the USS of administrative duties. The NHY Management oversight committee of the Self Assessment Team accepted the recommendation. NHY has established a schedule for implementing the recommendations by the end of 1989.

The Startup Test organization prepared and issued test procedures several years ago to support the propcsed low power testing scheduled .i to be conducted subsequent to the 1986 core load. These FSAR designated Startup test procedures were prepared per the Startup Test Program Description format, were revi3wed by the NRC, Westinghouse, NHY Quality Assurance, and were approved by SORC. Prior to conducting the 1989 Low Power Test Program, the technical content of these procedures was re-reviewed by Startup and Quality Assurance, and recommended changes were approved by SORC.

2. Aeolication of the Existina Procedure Compliance Policy Startup Test 1-ST-22, Natural Circulation, was revised, approved by SORC and reissued on April 14, 1989. Field Change Number 1, which provided additional instructions regarding references, initial conditions for secondary plant warmup and typographical corrections, was issued June 21, 1989.

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Discussions with Op rstions Group p3rsonnal indicated that thsy hid the opportunity to read the entire test procedure and that they were aware of the manual trip criteria listed on Attachment 9.3 of Startup Test Procedure 1-ST-22. Prior to conducting 1-ST-22, the Test Director briefed the assigned crew and made individual copies of the manual reactor trip criteria (Attachment 9.3) for the operators. The attached j chronology indicates that the Control Room operators were aware of the stated manual trip criteria and, associated with one of those 4

criteria, had started timing a 15 minute period to trip the reactor l unless they could recover from a Tavg of less than 541'F. In addition, they were calling out pressurizer levels during the conduct of the {

test. The USS specifically informed the Test Director of approaching the procedure trip criteria of pressurizer level less than 172. The Test Director did not appear to have acknowledged these communications regarding the approach to trip criteria nor the subsequent j communication by the USS that pressurizer level was below 172. The USS subsequently directed the primary board operator to inform him when pressurizer level approached 15I. Concurrent with interactions among the Control Room operators, there were a series of communications between the NRC und NHY Startup and Operations personnel regarding the level of the pressurizer below the 17I manual trip criteria setpoint.

Discussions with Operations personnel subsequent to the event indicate that they recognized the non-Technical Specification test parameters as conditions for Startup to either interrupt or terminate the test.

The Operations personnel also indicated that based on their own operations procedures and training they did not consider the non-Technical Specification, Startup test procedure trip limit at 17%

pressurizer level to be a limiting criterion because of the bounding nature and inherent conservatism for safe operation incorporated in the more familiar Excess Cooldown and Loss of Letdown Recovery system operating procedures.

Prior to leaving the Control Room, the Vice President - Nuclear Production, Station Manager, Operations Manager and Assistant Operations Manager were aware of the procedure violation. Within one and one half (1 ) hours of the event all of NHY's Executive Management was aware of a procedure violation and the need for corrective actions 9

,m, on procidura cdharanco. During thm courss of tha d2y. NHY managtmsnt:

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discussed the procedure violation'and the need to revise the policy regarding adherence to procedures. This was the sole topic of a one and one-half hour meeting on Thursday: evening where.the revised policy and corrective action options were discussed. On Friday morning a revised policy was established and it was directed that the revised policy be communicated to the Operations Group personnel through verbal:

presentations-by Station Senior Management, h-li NHY Executive and Station management met at 0645 on Friday June 23, 1989 to determine the proposed policy and schedule for corrective action. NHY subsequently related the revised policy and schedule'for proposed corrective actions to the NRC at 0730 on Friday, June 23, 1989 and began implementation later that day.

3. Conclusions-Analysis and comparison of the existing NHY procedure adherence policy with the events of June 22 and 23, 1989 provides the basis for the following conclusions:

(a) The assigned Operations shift crew should have followed the manual trip criteria in ST-22 and should have shut down the reactor when pressurizer level went below 172.

(b) New Hampshire Yankee did not fully comply with its own Administrative Controls, Policy and Guidance associated with procedure compliance.

(c) The Station and Operations Management policy on procedure adherence requires additional clarification to clearly delineate i those circumstances where it would be acceptable to deviate from j a SORC approved or Quality Assurance related procedure, q i

(d) The Operations personnel believed that the Startup Test Procedures, by their nature, were inherently flexible and did not require' verbatim compliance.

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(c) Startup Test personnel should have immediately considered and J 1

taken appropriate actions to recommend shutting the reactor down after being informed by the NRC that the plant condition had exceeded the indicated test trip criteria.

4. Procedure Compliance Policy Recommendations f

The following corrective' actions are recommended:

(a) Revise the Policy regarding adherence to procedures. This policy should clearly delineate under what conditions it might be acceptable to' deviate from an issued, approved procedure. These conditions must be based on compelling safety reasons:

(1) Protecting the public health and safety.

(2) Preventing personnel injury or life threatening situations.

(3) Preventing plant system, component, or structure damage.

(b) Incorporate the revised Policy in estab?.ished administrative and management manuals.

(c) Ensure that all NHY personnel receive initial and continuing training on the revised policy for adherence to procedures.

(d) Revise the Startup Test Program and procedures to:

(1) Rewrite and issue those Startup procedures, that would not ordinarily exist as Operations procedures, as Special Procedures that support infrequent evolutions and testing.

The preparation, alpha-numeric designation, review, approval and distribution of these procedures should be brought into full compliance with the existing guidance in the Station and Operations Management Manuals.

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(2) Provide additional guidance for terminating the test and exiting .the test procedure when plant transients or .

J equipment malfunctions occur during the conduct of tests. j l

(3) Establish a program to conduct additional review and rehearsals for the test crews in the classrocm and on the simulator, as necessary, when complex or unfamiliar test p procedures will be conducted. I C. Post Trio Review Policy l

1. Background and Existing Policy l

New Hampshire Yankee reviews and analyzes unplanned reactor trips.

Engineered Safety Features (ESF) actuations and other similar significant operational events through a series of integrated procedures performed by the Operations Group, an independent Event Evaluation Team composed of NHY individuals with the requisite experience r.nd training to provide immediate analysis, a Root Cause analysis conducted by the Reliability and Safety Engineering Department and two other overall mandatory reviews by the Station Operation Review Committee (SORC) and the Nuclear Safety Audit Review Committee (NSARC).

The specific requirements and conduct of activities are delineated in the following:

1 (A) Technical Specification 6.4.2.7

,l "The NSARC shall be responsible for the review of: l l

e. Violations of codes, regulations, orders, technical 1 i

specifications, license requirements, or of internal ]

pro'cedures or instructions having nuclear safety i

significance:

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g. ALL REPORTABLE EVENTS" (B) Technical Specification 6.5 - Reportable Event Action l 12

The:following' actions shall be taken for REPORTABLE EVENTS:

a. The Commission shall be notified and a report submitted

. pursuant to the requirements of Section 50.73 to 10 CFR Part 50, and-

b. .Each. REPORTABLE EVENT shall be reviewed by the SORC and the results of this review shall be submitted to the NSARC and the.Vice President - Nuclear Production.

(C) Operations Procedure OS 1000.08, Post Trio Review.

(D) NHY Procedure 12830, Event Evaluation and Reduction Program.

(E) NHY Procedure 12810, Root Cause Analysis.

(F) NHY Reporting Manual, Station Information Reports.

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1 The intent of these activities is to provide a thorough, detailed analysis of the physical plant, as well as the procedural and personnel factors that were .the root cause or contributing factors to the event. )

By design, portions of this analysis must be initiated and the entire Operations Post Trip review (OS 1000.08) must be completed to the satisfaction of Station management prior to an authorized restart of

.the reactor.

2. Aeolication of the Post Trio Review Policy 1

The attached chronology provides a detailed account of the substantive activities and communications relevant to the post trip review process and NHY involvement in reviewing and analyzing data, developing resolutions to identified problems, and implementing corrective

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1 actions. The following narrative addresses certain key events and activities and incorporates the perspectives of NHY personnel interviewed as part of this report.

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was in c st2ble condition. Making usa of ths incrcastd numbar of operators present, the Assistant Operations Manager directed the on-coming Shift Superintendent and Unit Shift Supervisor to begin the post ]

trip review data collection in parallel with the assigned shift l performing the notification process. At 1320 the assigned Shift Superintendent completed the NRC offsite notification. This

[ communication reported the following:

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"While performing low power physics testing, Startup test procedure 1-ST-22 Rev. #2 (Natural Circ.), Tavg had reduced to below 541'F, pressurizer pressure at 2340 PSIG and pressurizer water level less than 17%; these were manual trip criteria per y procedure. M.S-P3011 stuck open causing initial cooldown."

The INPO Nucicar Network (PS section) contained the following summary I of the June 22, 1989 Seabrook reactor shutdown based on this communication. 1 Facility  : Seabrook f Event Date  : 06/22/89 l Time  : 12:35 EDT  !

Unit  : Unit  :

Emergency  : Not Applicable Reactor Trip (1)  : Auto with Rod Motion Reactor Trip (2)  :

Reactor Trip (3)  :

Reactor Critical  : Y Prior Mode  : Startup Prior PWR  : 003 Current Mode  : Hot Standby Current PWR  :

WITH THE UNIT AT 3% POWER AND ATTEMPTING TO ESTABLISH NATURAL ,

CIRCULATION AS PART OF A LOW POWER PHYSICS STARTUP TEST PROCEDURE, A MANUAL REACTOR TRIP WAS INSERTED DUE TO A TRANSIENT INITIATED BY A i FAILURE OF A STEAM DUMP TO THE CONDENSER. DURING THIS TEST A STEAM DUMP FAILED CPEN. THE STEAM DUMP WAS THEN CLOSED BY CYCLING IT. THE TEST WAS CONTINUED. HOWEVER. THIS SEQUENCE WHILE ATTEMPTING TO ESTABLISH NATURAL CIRCULATION RESULTED IN T(AVE) BEING REDUCED TO 541 DEGREES. PRESSURIZER LEVEL BEING REDUCED TO JUST LESS THAN 17% AND THEN I PRESSURIZER PRESSURE INCREASING AGAIN TO 2340 PSI. THESE WERE ALL CRITERIA FOR MANUALLY TRIPPING THE UNIT PER THE STARTUP TEST PROCEDURE.

ALL SYSTEMS FUNCTIONED AS REQUIRED FOR THE TRIP AND UNIT IS NOW STABLE IN MODE 3. PRESSURIZER LEVEL HAS BEEN RETURNED TO NORMAL. FOUR REACTOR COOLANT PUMPS WERE RESTARTED WITHIN ABOUT 30 - 45 MINUTES.

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The three trip. criteria' indicated in this report were three of several trip criteria listed.in Attachment 9.3 of_1-ST-22.- Comparison with

. actual events, the procedure and technical specifications indicate-that: 1 Y

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-(1) The' Pressurizer level'went below 172 for approximately five '

I minutes but had been recovered to 212 at the time'of the manual .]

reactor trip.- Pressurizer level below 17Z'is a non-Technical-Specification trip. criteria listed in 1-ST-22.

(2) The Tavg less.than 541*F criteria has a 15 minute window to correct the condition (Technical Specification 3.10.3 ACTION Statement b) or to place the reactor in Hot Standby within the next 15 minutes. Tavg vent below 541'F at 1232:50 and was noted by Operations personnel. .The reactor was shut down prior to the

. action required by this criteria.

(3) The USS directed the shut down'of the reactor in anticipation of-reaching the pressure trip criteria of 2340 PSIG.- The actual peak

- pressure was 2310 PSIG and therefore this trip criteria was not exceeded.

At 1423 on June 22, the Test Director initiated a Station Information Report (SIR), which is an additional method for NHY to document an event or condition for further review and analysis. The SIR becomes the document which encompasses or includes the Event Evaluation Team Report and the Root Cause Analysis. The SIR includes recommended 4

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-i corrsctivs' actions which' ore revicwid by SORC cnd NSARC. SORC'and NSARC review the: entire package'for the adequacy of the review, j I

analysis-and recommended corrective actions. 1 1

The on-coming Shift Superintendent and Unit Shift Supervisor began implementing Operations Procedure OS 1000.08, Post Trip Review,'at 1250-3

.: on' June 22. This procedure provides a detailed checklist, with 'l required signoffs, that focuses on gathering Post Trip /SI data, evaluating.the data and making a recommendation for plant startup. The'  ;)

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'l assigned SS, USS and SCR0 completed the post trip review and submitted 1 l

.it to the Operations Manager at approximately 1700. The Station Manager reviewed the post trip review document package at 1755 and .j 1

-i indicated'that reactor restart would'be' contingent upon his personal'- 'J approval.

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The Operations notification process includes contacting the assigned Site Emergency Director (SED) for any reportable event. NHY Procedure 12830, Event Evaluation and Reduction Fronram, further requires the SED to assign an Event Team Leader to begin data gathering and analysis, assist the Shift Superintendent in the completion.of OS 1000.08 and to communicate this information to then f I

• Director of Corporate Communications

• NSARC Event Reduction Committee Members

• Station Manager

' Vice President - Nuclear Production

' Vice President, Engineering, Licensing and Quality Programs 1 1

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• President {

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'.NRC Residsnt Inspictor-1

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• Regulatory Services Manager Pq *

- ' ISEG Supervisor

• Event Evaluation. Team Members-s This procedure a1so integrates the paralle1' activities associated with-

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the Post Trip Review and Station Information Report' processes and serves as an' input to.the Root'Cause Analysis Procedure 12810.

The chronology indicates that the assigned Site Emergency Director

. initiated the Event Evaluation Team (EET) at approximately 1330. The Event. Team Leader began the data gathering and analysis and assisted

~1 the. assigned' operations shift crew in completing the Pos't Trip Review.- I The EET debriefed the assigned shift crew and had the sequence of  ;

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physical plant events and responses completed prior to the Station ]

Manager's post trip review critique at 1500 in the Technical Support Center. The Event Evaluation Report will be attached to the SIR and

. reviewed by SORC and NSARC.

l At approximately 1515 on June 22, the Station Manager commenced the  !

verbal debriefing of the events that caused the reactor shutdown. The

. preliminary results discussed at this meeting were (1) The sequence of events, starting with the initiation of 1-ST-22, {

based on various plant data collection systems.  ;

(2) The primary side of the physical plant responded to the events and reactor shutdown as anticipated.

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- (3) The secondary side of the plant responded.to the events' as anticipated and designed with the exception of.the condenser steam dump valve.

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(4) A. work request was initiated to correct MS-PV-3011, the condenser g.

1; steam dump valve that caused the excessive cooldown.

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(5)- A work request was. initiated to investigate what evolved to be an unrelated 'D' Main Steam Isolation Valve. position problem (an air:

, maintenance pump sticking pilot valve lead to component replacement to resolve the problem).

'(6) The Startup Test Procedure,'(1-ST-22), trip setpoints were adequate and required no revisions.

(7) The Operations Post Trip Review EET and SIR had been' initiated.

The Station Manager reviewed the actions necessary for completion of the event evaluation to support a tentative restart the next day.

Discussions regarding the violation of procedures and procedural corrective actions were intentionally excluded in order to focus the discussion on physical plant. This critique ended at approximately 1630.

At approximately 1630 the Vice President - Nuclear Production and Station Management met to prepare for an 1800 conference phone call with the NRC Region I, to explain the events that transpired during the 18

m Natural Circulation' Tost cnd to'iscuss d the corrsctiva actions that NHY- j either had in progress or anticipated to be necessary prior to restart.

A discussion of the Startup procedure and Station policy on procedure )

adherence concluded with the recognition that the reactor should have.

been shut down, the recognition that the procedure adherence policy required resolution prior to restarting the. reactor and that Operations

, pensonnel should be indoctrinated on any policy changes prior to l'

restarting the reactor. The discussion also included consideration of' the operator's actions based on normal operating parametets and procedures which would have explained the operator's actions from a technical'and operational basis. This brief period, prior to the 1800 telephone conference call, did not provide sufficient time to fully develop and finalize the proposed policy revision.

At 1800, NHY, on-site NRC inspectors and NRC Region I personnel conducted a telephone conference call to discuss the reactor shutdown.

NHY described the chronological sequence of events and actions currently in progress to determine and correct the failure mechanism for the condenser dump valve and the position indicator for the 'D' i MSIV. NHY also indicated that the physical parameters of the plant responded as anticipated and designed and that based on current maintenance activities, it was estimated that the plant could be made j

ready for restart by 0700 on Friday, June 23. 1989. NHY proposed to place the plant in a reactor critical, standby mode in anticipation of L correcting the physical impediments prior to resuming low power te s e.ing .

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COL l'.^

l k'QV6 LDuringjtha: discussion. NHY dsscribsd the b3 sis for the operator's-0 Jactions taken during the event.L'It was explained,that the'USS was in

. command and the operators; felt that they.had control over the.cooldown-sequence. 1 The operators recognized that.they were below the test

'I procedure pressurizer low level trip limit; but. knew.that they were within the parameters and. criteria listed in'the~Technica11

~

Specifications,and Operations procedures. -Notwithstanding their Eprocedure violation error..the operators had.taken otherwise appropriate actions to restore'the pressurizer level.and.to re-establish the. test parameters. Once'they became aware ~of the cause, the operators'took corrective action to close the condenser steam dump,

~

valve and thereby terminate the unanticipated excess cooldown. 'Four-minutes and forty-eight' seconds (4:48) after isolating the condenser steam dump valve the USS ordered the reactor shut'down when he.

determined that the. plant might possibly exceed pre-specified' plant parameters before normal operating system lineups could be fully restored in a conservative, controlled fashion.

With regard to test-procedure adherence, the NHY position was that although the USS and board operators had taken actions to operate the

, plant in a safe and technically sound manner, they had inappropriately violated the specific manual reactor trip criteria listed in the test procedure. NHY's position was that the USS should have immediately directed the reactor shut down when the pressurizer level reached the 17Z test limit.

j.

20

= _ _ _ _ _ _:_ _ _ _ _ _

d

'NHY cnd tha NRC agreed that a follow-up confersnce call-would occur at 0730 on Friday morning and that.NRC concurrence would be achieved prior n

to restarting the reactor.  !

1

,R 1

u At approximately 1830, NHY Production and Station Management continued their, discussion of procedural adherence begun at their previous 1630 h .1 meeting'. This meeting continued until approximately 2100 and adjourned

f.  ?)

l with.the following conclusions and corrective actions:

I

-- The 1-ST-22 Manual Trip Criteria, indicated on Attachment 9.3 to the procedure, was appropriate and should remain in the procedure. )

~!

.j The USS should have ordered the' shut down of the reactor.

-- NHY needed stronger policy and guidance regarding procedural' adherence.

At approximately 2315, after having arrived home from Washington, DC, the NHY President and CEO phoned the NHY VP-NP for a status report.

The VP-NP provided a brief summary of the 1800 conference call with the I

NRC Region I (Wiggins) making the following points:

-- The NRC "seemed to be pretty well satisfied" with the NHY explanation of the details of the event.

-- A couple of hardware corrective actions and some relatively minor .

procedure changes needed to be taken care of, but once these were concurred with by the NRC, the plant should be ready for restart.

21 1

u________.---_-_-_-_--__--_.____-_-___-. _ . _ - _ - - _ _ _ - . _ - _ - - _.

7 7- >

c ,. . , s

& , ,8 ;; ,

SWy ,

n 7Y. > , .., .

-- . NHY.hadL committed to review wit!h the NRC, its schedule of.

1 7j completion.of' hardware corrective' actions such as'the corrective-5 ., . [g  ;

'fmaintenan'ce being' performed on'the steam dump' valve that had w" E-

. malfunctioned during the. test.

':y G; 4 .-

,Another conference ~ call with NRC Region I had been scheduled for.

0730 Friday morning to review these items.

,, I gc. ' ' 'TheLVP'-NP then spent a few minutes focusing on'the procedure compliance issue and-reviewed.the NHY management group's proposed position that had1been: developed following the 1800 conference call with~the NRC..

lThe President and CEO indicated that he would participate in the.0730 conference callon Friday.

NOTE - The President and CEO was not made~ aware, either during th'is-briefing or during the next morning's 0645 pre-NRC telecon briefing,.of a number'of key facts associated with the 1800 NHY/NRC-telecon; i.e. the defense of. operator actions taken or not taken, the suggestion that the operator actions were i-more conservative than strictly adhering to a test procedure, the feasibility that the NHY procedure compliance policy was essentially adequate as written.and.the proposal that reactor restart be allowed to occur in parallel with NRC/NHY event

~

evaluation conclusions and corrective action determinations.

r ,

}

22 i

1

_L -_ f E - . __

At 0730 on Jun] 23, 1989 NHY, NRC Rhgion I cnd on-site NRC insp2ctors participated in a_ telephone conference call that was a continuation of the discussion from the previous evening. The topics discussed i 5

-included:

1

}

l

-- The 1-ST-22 procedure, including the manual trip criterin, was appropriate and that revisions were not required. .{

[

-- NHY had adequate existing procedure adherence guidance that applied to static conditions but that this guidance was not fully satisfactory for unanticipated transient or emergency conditions.

The NHY policy recognized that strict, verbatim compliance to procedures would not always be appropriate during such transient or emergency conditions. Otherwise NHY personnel are expected to follow procedures. NHY recognized the need to revise the procedure adherence policy to accommodate an unanticipated transient or emergency situation.

-- NHY proposed that the procedure adherence policy would be revised and issued through SORC within two weeks. The Station Mant.ger would brief each operating crew prior to their assuming their next assigned shift. NHY would conduct ongoing procedure adherence training.

-- NHY related the status of the prerequisite actions considered to be necessary prior to a resctor restart and estimated that they could be resolved prior to 1030 that day.

23

y J;

^ " -

,The NRC.indicatGd thet thsy h d no cdditional quastions.but g expressed the need to further brief their management. The NRC.

committed to respond to NHY by 1000 and requested that NHY not

-restart until after the return telephone call.

y

[ 4 .The 1000 NRC. return phone call did not occur, and at approximately 1030

.the Vice President - Nuclear Production phoned the NRC Region I to indicate that the restart readiness target had been slipped to 0700 on Saturday, June 24, 1989.

Reference to the attached chronology also indicates that numerous additional internal (NHY - NHY) and external (NHY - Others) commur.ications occurred between individuals and at impromptu meetings.

3. Conclusions Analysis and comparison of the existing NHY Post Trip Review Process with the actions taken in response to the events of June 22 provides the basis for the following conclusions:

(1) NHY should have allowed the existing, conservative and deliberate l

\

approach to analyzing the events of June 22, 1989 to be completed-before discussing restart schedules with the NRC. The following actions should have been completed:

1 J

(a) Completion of a thorough and detailed analysis of the physical events that had initiated the unanticipated a

24 I

L ,

transient as w311 as the oparator actions takan in responding to the transient.

(b) Completion of corrective maintenance and post maintenance testing for the specific component'that failed and a l-

[ determination that similar components did.not exhibit the

} same condition.

(c) Completion of the determination and dissemination of revised corporate policy on procedure adherence.

(d) Completion of Operations and Startup personnel specific training'on the revised policy.

(e) Completion of the' Event Evaluation Team Report.

(f) Completion of.a NHY Executive Management meeting with the NRC to brief them on the results of the completed analysis and l the status of in-progress corrective actions. ,

-l (2)' NHY should have more fully utilized the Event Evaluation Team leader as the communications focal point within NHY. This is currently described as a primary function for this position.

(3) NHY should have designated single points of contact to provide information to individuals or groups, both internal and external to NHY, for this events i.e. NHY to NRC, NHY to State. NHY Production to the rest of NHY.

25 1

!t s1 g .

(4) Communications with th2 NRC should hava more accurately conveyed; m

h ' that the total NHY post trip review process was still in progress,-

is

,that the event conclusions were.still being-determined,Lthat-restart decisions were still being made and that even though plant y  : equipment corrective actions were being taken in' order to establish physical plant readiness to restart, no restart

' determination would be made until all NHY and NRC concerns had been fully addressed.

(5) The NRC required (10 CFR 50.72) report should have been more accurate. The NHY four-hour reportable event communication to the NRC (Bethesda) on. Thursday at 1320 was inadvertently incomplete, inaccurate and may have been a. source of miscommunication regarding the actual event.

(6)' The ovent' evaluation review process should have more adequately addressed the procedu.re or personnel contributions to events.

(7) NNY should not have conveyed'an inappropriate focus on resuming the Low Power Test Program and should not have engaged in inappropriate justifications of the operator actions taken in responding to the event.

(8) NHY personnel contacted by the NRC during the performance of 1-ST-22 andni' formed of the pressurizer low level trip criteria should have more appropriately conveyed this information, in a timely and effective manner, to NHY management.

26

.4.' Post Trio Review Policy Recommendations (1) NHY should reinforce its policy of using a deliberate -cautious and conservative approach when responding to future unplanned reactor shutdowns or ESF actuations. NHY should emphasize the completion of the full post trip review process including a discussion of'the results with the NRC prior to recommending the restart of the reactor or the resumption of testing. During power ascension testing the Event Evaluation Report should be completed prior to recommending the restart of the reactor.

(2) NHY Operations should' review the 10 CFR 50.72 reportable event notification process to determine the need to use a preparer and reviewer methodology prior to actual transmittal of the report.

NHY Operations should also consider confirming the reportable event communication by verification on the same day or by a next day comparison of the INPO Nuclear Network data base.

(3) NHY should review the effectiveness of the current internal and external post event communications processes and the assigned responsibilities to ensure that management expectations will be met in terms of timely, focused, accurate communications appropriate to the significance of the event.

(4) NHY should re-evaluate the overall post trip review process for unplanned reactor shutdowns and the assignment of personnel by position (i.e. Operations Manager or Assistant Operations Manager) to the Event Evaluation Team. These key management positions 27

4 h D retain lins' man gtment responsibilities irresp2ctiva of the current post trip review processes. .The direct participation, by these individuals,.in the event evaluation process will assure that the individual (s), with the decision making. responsibilities

.. leading up to restart of the unit, will be fully aware of the f post trip review status and conclusions.

l-(5) NHY should further review the event evaluation process and should evaluate the adequacy of its present criteria that concern procedure and personnel contributions ;o events. NHY should:

r (a) consider incorporating the post trip review critique meeting (held in the TSC) as a standard practice.

(b) require each key participant in the event to prepare a written, chronological report as'part of their post trip report debriefing, and (c) upgrade the event evaluation process with respect to human factors and performance analysis and corrective action determinations.

(6) NHY should aggressively pursue resolution of these recommendations and complete implementation prior to Power Ascension Testing.

28 m_m_.__ _ . _ _ _ _ _ . _ _ _ . _ _ _ . _ _ ._ _. _ )

m m :n . 4 j ..

D. ' Steam Dumo Nalve Incomplete' Work Recuest-

1.

Background:

L-1.

The-steam' dump valve, MS-PV-3011, that was the cause of the unplanned' plant cooldown, had an'open work request pending completion'of a normal operating pressure, normal operating temperature dynamic flow and

~

stroke time retest. This retest was a NHY identified and conservative

. opti on sel ected to further determine valve operability and

- functionality following some corrective maintenance performed subsequent to the second Seabrook Station Hot Functional during February'of 1987. Although'it was being tracked by the Station. Work' Control Planning and Scheduling process, this retest was'not conducted prior.to the Natural Circulation Test. Several requests had been made by the retest implementation department (Instrumentation and Controls) but plant conditions.did not allow retest at those times.

It can'not be. determined at this time (post event) whether the specified retest would have.successfully identified the MS-PV-3011 impending failure or not. The retest called for a one-time, rapid stroke of the valve to verify freedom of movement over one full cycle 1

from full shut to full open to full shut and to collect valve stroke timing data. Because the valve appeared to operate correctly during )

the preparations for and the onset of the Natural Circulation Test, it most probably would have successfully passed the retest without the

.)

subsequent valve binding and positioner feedback linkage problems becoming evident. ,

l 29

2. -Conclusions l, 1. Seabrook Station Technical Specifications do not require that this -

valve be OPERABLE during' MODE 2 operation of the' plant.

f.

2. By the S'eabrook Station Maintenance Manual operability test n criteria and the specified retest. criteria determined to be appropriate s.ubsequent to the corrective maintenance performed 'on this valve. MS-PV-3011 had not been determined to be OPERABLE nor had the operability retest been waived through the applicable NHY justification / documentation procedures.

3. The Startup Test Program Description requires that temporary modifications and tag outs be evaluated but does not require.that open retests be identified or addressed prior to the conduct of a Startup Test.

1-ST-22 did require, as a prerequisite, that the Steam Dump System be available for use. System availability was specifically considered and was determined to be satisfied by virtue of the system use during the Emergency Feedwater System testing completed-on June 12, 1989 and use during the June 22, 1989 pre Natural Circulation Test preparatory activities just prior to 1-ST-22 performance.

30

s

. k. i

3. Recommendations:

1.  : Resolve- the Steam Dump Valve positioner feedback linkage 'and valve L

binding' problems on the twelve steam dump valves and other Seabrook_ Station val'ves that are of similar design and provided by the manufacturer of these valves.

-2, ' Revise the Startup Test Program Description to require consideration of-any outstanding retests associated with equipment to be used in any specific Startup test. -Outstanding-retests so identified should either be performed or waived through.

an acceptable.-documented process.

j i

, 31

4 ATTACHMENT NHY MANAGEMENT EFFECTIVENESS CHRONOLOGY Thursday, June 22. 1989

{>

L 1030 -- The Natural Circulation Test (1-ST-22) Test Director completed the-on-shift operator's pre-test briefing.

1125 -- (1-ST-22) Prerequisites, Special Precautions, and Initial Conditions sections completed.

1205 -- (1-ST-22) Test Instructions 6.1 through 6.5 completed and the Test-Director signified readiness to initiate natural circulation to the Unit Shift Supervisor.

.1219 -- Reactor coolant' pumps tripped to initiate Natural Circulation (1-ST-

22. Test Instruction 6.6) Test.

Approx.

1225 -- The primary side board operator started announcing to the Unit Shift Supervisor (Operations individual in charge) the decreasing Pressurizer (PZR) level values. The primary side board operator was instructed to regain control of pressurizer level through use of letdown and charging by the USS.

1228 -- The Unit Shift Supervisor (USS) announced to the Test Direct 3r that PZR-level was approaching 172 lower level test limit.

1229 -- Pressurizer level reached the lower level test limit of 172 and letdown isolation occurred. The USS informed the Test Director of letdown isolation, announced 15% PZR level as the next operator decision point and requested verbal reports from Main Control Board, primary plant board operator on his ability to tenninate the PZR level decrease.

At Unknown Times -- NRC Inspector (Trapp) informed the NHY Startup Manager of PZR level less than 17%.

1

(t[ '

E NHY MANAGMENT EFFECTIVENESS CHRONOLOGY

l. '

e

(; -- NRCLinspector (Trapp) informed the Startup Test Director of PZR level less than 172.

-- The Startup Test Director confirmed that the USS knew of PZR level less than 17I.

L

-- NRC Senior.Residen.t. Inspector,(Dudley) and NRC Inspector (Trapp) informed.the Assistant Operations Manager.of PZR level less than 17%.

-- The Assistant Operations Manager confirmed the Startup Test Director and USS awareness that PZR level was less than 172.

-- These and other NHY management present in the Control Room deferred to the USS's command authorities and responsibilities.

NOTE: At that time and in the absence of any other cause NHY management did not perceive the need to intercede. Most were unaware of.the test trip limits and there was adequate indication that the USS was aware of'the plant condition, was making progress in controlling the PZR level decrease and was controlling plant parameters within normal, licensed, operating limits even though he was, at-that point, outside of the specified test limit of 172 P2R minimum level.

'1231 -- Steam Dump Valve PV-3011 reported as open and was immediately closed

• PZR level reached its event minimum value of 14.5Z.

PZR pressure reached its event minimum value of 2179 PSIG.

Charging rate of 122 gpm and reduction in steam demand (closure of PV-3011) initiated rapid PZR level and pressure recovery.

1

. 2 l

i NHY MANAGMENT EFFECTIVENESS CHRONOLOGY

~1233 --- The Shift Superintendent informed the USS that Tavg'had just gone below 541*F and that.the USS should note the start of the-15 minute i requirement to restore Tavg >541*F or be in HOT STANDBY within the next c 15 minutes. The USS acknowledged and directed the Startup Test Director to keep him informed of temperature changes.

1234 -- PZR level returned'above 17%. '!

1236 -- .The USS directed manual Reactor Trip with PZR level at 21% and increasing,'PZR pressure at 2310 PSIG and increasing (which was 30 PSIG in advance of the 1-ST-22 manual trip criterion of 2340 PSIG).

1236 -- The USS directed E-0 plant recovery procedure entry and return of the plant to HOT. Standby conditions without further plant personnel or equipment recovery problems or events.

NRO Deputy Region Administrator (Martin) informed the NHY Vice-President - Nuclear Production that Reactor Trip had not been initiated at 17% PZR level l'n accordance with 1-ST-22' criteria.

1237 -- The Assistant Operations Managers l

Informed the Operations Manager of 1-ST-22 procedure adherence violation (less than 17% PZR level).

Directed the Shift Superintendent to retain shift for critique.

Assigned the on-coming Shift Superintendent to conduct Operations Procedure OS1000.08, " Post Trip Review".

Directed the on-shift Shift Superintendent to carry out 10 CFR 50.72 (4) hour NRC notification.

Approx.

3

.G g.

NHY MANAGMENT EITECTIVENESS CHRONOLOGY f

-i

'1245 -- Meeting in'the Station Manager's office to discuss 1-ST-22 termination j and manual. Reactor Trips .

• -'Cause

-' Sequence of: Events

• .17Z PZR Level Violation g Post Trip' Review Plan / Schedule

' Event' Evaluation Team Initiation

-- Vice-President 1- Nuclear Production (VP-NP) telecon to NHY Corporate Communications Staff to brief them on the events.

4

-- VP-NP 'telecon to Executive offices to infonn other Corporate

. individuals of the events..

1300 - ' The VP-NP convened a Production management / supervision meeting to discuss'1-ST-22 te.rmination and manual Reactor Trips

~t

• Cause ~

Sequence Of Events

Confirmation of the 17% Procedure Violation and lack of Adherence to Procedures Determine Activities / Actions That Needed To Be Taken Prior To Plant Restart Review Data Accumulated Up To That Point In Time

-- The VP-NP stressed the importance of a complete and thorough review of the activities leading to and following the trip prior to plant restart.

1315 --- The Shift Superintendent called Corporate Communications Representative with plant trip details and his impending notification of the NRC.

4 l

l L - __-- -_ ._ _

kW  ?

4 h'<

' ;n '

, NBY MANAGMENT EFFECTIVENESS CHRONOLOGY s'

L U .

1320 --- The Shift Superintendent' called:the NRC with 10 CFR 50.72 notification l , ' facts. ' Inadvertent'miscommunications of plant parameter details and

plantLmanual trip criteria occurredLduring this-telecon.

g '1330 --- lThe;Startup Shift-Test Director was designated the NHY Events o ,

. Evaluation and Root Cause Analysis Team; Leader (NHY. Procedure Numbers 12810 andE12830) by the Manager of Operational Support per Station Manager-direction..

The Event Evaluation Team Leader pulled GETARS data and started evaluation'.

LApprox.

< '1331:-- The VP-NP and Station' Manager. privately discussed the lack of procedural adherence. occurrence its severity.and established' initial J . direction'on how to proceed in determining management actions-Appropriate to the severity of the occurrence.

c . Approx.~.

1350 -- :The VP-NP called the NHY Washington, DC Licensing Office to' inform the President and CE0'and VP-Engineering, Licensing and Quality Programs.

of the event occurrence, actions completed to that point in1 time.

appraisal of the NHY and NRC concerns over appropriateness of operator response, actions anticipated to be necessary prior to restart'(post trip review, PV-3011 troubleshooting / repair / operability determination or isolation, and short term procedure adherence resolution). At that

]

time, the VP-NP' conveyed that the NRC had expressed concerns but the 'l NRC on-site individuals also seemed to convey that NHY actions thus far had been controlled and appropriate. No communications to the contrary had been received by the VP-NP.

j Earliest estimated physical plant readiness for restart was then i estimated to be Friday AM, 0700, June 23, 1989. ,

5 l

J

_____1_________._.______._. . _ _ . . _ _ _ _ J

NHY MANAGMENT EF7ECTIVENESS CHRONOLOGY 1400 -- The Manager of Operational Support, as part of the Event Evaluation Team, and as part of the Low Power Testing Self Assessment Team commenced interviews of on-shift operations crew.

-1410 -- The VP-L.E,& QP called-the Self Assessment Team Manager to confirm his awareness of the events and to ensure that Self Assessment as well as NHY Event Evaluation team evaluations were on-going. The SAT Manager was not personally aware, up to that point, but found that other SAT.

members and the NHY Event Evaluation Team had already been activated.

l 1

1415 -- The Manager of Operational Support and SAT member briefed the SAT l

Manager.

1430 -- The Startup Manager' briefed NRC Inspector (Trapp) of data collection in progress, post trip review process prior to restart,. event evaluation team activation and estimated the preliminary event evaluation summary to be completed by 1800.

-- A NRC Inspector (Trapp) question regarding the length of time between the less than 172 PZR level condition and the Reactor Trip could not be answered at that time, but the Startup Manager promised to answer when the value could be determined from Main Plant Computer System (MPCS) or GETARS printout data. l

\

1430 -- The SAT Manager briefed VP-E,L&QP in NHY Washington, DC Licensing Office on event sequence and status of event evaluation activities in I progress as well as planned.

1445 -- NRC Senior Resident Inspector (Dudley) requested that the NHY NRC Coordinator provide post-trip review data access for NRC review and l that the NHY restart not occur until the NRC had signified concurrence i I

with the restart decision. 1 i

6 I

NHY MANAGMENT EFFECny--4S CHRONOLOGY 1450 - . The NHY NRC Coordinator took the NRC Senior Resident Inspector (SRI) to-the Station Manager's Office. The Station Manager informed the SRI that this restart was already conditioned upon the Station Manager's personal approval, that he would ensure that the SRI had access to.

'Whatever he needed and as of that conversation, this restart would not.

occur prior to the SRI being afforded an opportunity to review the data.

1500 to 1620 -- Post. Trip Review Critique conducted in the~ Technical Support Center (TSC).

Attendees: Station Manager Unit Shift Supervisor (Spare)

Shift Test Director (Off-Going) and Event Evaluation Team Leader Supervisory Control Room Operator (Off-Going)

Shift Test Director (On-Coming).

Tes.t Director for 1-ST-22 Manager of Operational Support Startup Manager Technical Support Engineer Assistant Station Manager Shift Superintendent (On-Coming)

Shift Superintendent (Off-Going)

Day Shift Superintendent Unit Shift Supervisor (Off-Going)

Reactor Engineering Department Head Assistant Operations Manager Operations Manager NRC Senior Resident Inspector (Part-Time)

Shift Technical Advisor (Off-Going)

[

! Control Room Operator (Off-Going)

Unit Shift Supervisor (Spare) 7

NHY MANAGNENT EFFECTIVENESS CHRONOLOGY Independent Review Team Representative Discussion Items: (All procedure adherence evaluation / analysis was intentionally excluded from this critique due to the size of.the participating group and because it was being addressed at the Station Manager - VP-NP level.)

1.) Tech Spec Action Statement Limiting Condition for Operation 3.10.2.b.

2.)' Chronological Sequence of Events.

3.) Steam Dump Valve malfunction, consequences, control bank sequence, steam flow worth for each valve, control. system design, anticipated and unanticipated effects, plan of-action, responsibilities, schedule and actions to be taken_

prior to restart.

4.) Reactor Trip Plant Response:

• Primary Side L

• Secondary Side

• Reactor Protection and ESF Systems Response f 5.) 1-ST-22 changes to be evaluated / acted upon prior to any retest.

6.) Command and Control issues with the large observer audience in the Main Control Room.

7.) All factors influencing the trip and subsequent trip recovery.

8.) SIR, EET', Operations post-trip review progress.

8

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E NBY MAHAGMENT EITECTIVENESS CHRONOLOGY F

9.) All actions, known at that time, necessary prior to restart.

10.) ' Action item assignments and schedules.

E Approx.

- 1620 -- The' SRI called VP-NP requesting that the VP-NP participate in a.telecon' with NRC. Projects Branch Chief (Wiggins) at 1800.

1630 -- The VP-E.L&QP requested that the NHY Bethesda Licensing Office representative contact and brief the NRC NHY Project Manager'(Nerses) on sequence of events to that time.

1630 -- The VP-NP convened a Production management analysis and briefing session, in the Station Manager's office, to prepare his positions'in advance of the scheduled 1800 telecon with the NRC Projects Branch

-Chief (Wiggins).

{ 1645 -- The Shift Test Director, the. Reactor Engineering Department Supervisor I.

l and'the Startup Manager convened a meeting to analyze and determine changes (if any) necessary prior to performing 1-ST-22 again.

1700 -- 051000.08 " Post Trip Review' procedure completed by the assigned Shift l Superintendent, the assigned Unit Shift Supervisor, the Shift Technical L Advisor and the on-shift Shift Superintendent. Document delivered to Operations Manager.

' 1800 -- The Operations Manager informed the SRI that the Operations Post Trip Review Procedure was complete and available for NRC review in the Operations Manager's office.

i 1800 -- VP-NP initiated telecon to NRC Projects Branch Chief (Wiggins).

9

, )

l

' NHY MANAGENT EFFECTIVENESS CHRONOLOGY i

Participants:

J. Wiggins - NRC Projects Branch. Chief j i

N. Dudley -- NRC Senior Resident Inspector i L. Privedy -- NRC Inspector -

Vice President - Nuclear' Production l

.q

' Station Manager .]

1 Assistant Station Manager

. Operations Manager Manager of Engineering' Manager of Operational Support I

(1) NHY described the chronological sequence of events.

I

.s (2) Actions being taken to determine PV-3011 failure, repair and-f restoration to full operability. )

(3)' Plant systems and componente response to the Reactor Trip ,

.l (normal).

i

(

1 (4) Operator actions taken during the event:

l USS was in command and his crew had adequate control over the cooldown sequence. The operators knew that they were below t

the test limit, knew that they were within Technical Specification and operating. limits and were taking actions to l

restore the plant to pre-test conditions.

[-

Took immediate corrective actions once the source of the unexpected cooldown was determined (Steam Dump Interlock control placed in OFF causing PV-3011 to go shut).

The USS ordered a manual reactor trip 4 minutes and 48 seconds later when it became apparent that pressurizer pressure would approach the manual reactor trip limit of j 2340 psig. f 10 j

g- -

ff ,

! , NHY MANAGENT EFFECTIVENESS CHRONOLOGY p

l (5) With respect'to test procedure adherence, the NHY position was that although the USS had.taken the appropriate actions to operate the plant in a manner'that was safe and technically justifiable,

.he had. violated test procedure manual reactor. trip limits. After p specific evaluation of this issue, the NHY position was that the USS should have tripped the plant when he first reached the 17%

PZR low level test limit.

.(6) NHY corrective actions anticipated prior to restart would include:

Review and assessment of the adequacy of the pertaining test procedures and NHY procedure compliance Policy and guidance.

Resolution of Steam Dump Valve operability.

(7) NRC'(Wiggins) expressed that procedure adherence violations and the subsequent management corrective actions were of significant concern to the NRC, that he wanted to discuss this telecon further with his management, that he wanted to talk again at 0730 Friday AM, June 23, 1989 and he requested that further testing be deferred until all Steam Dump Valve and investigative issues were resolved.

j (8) VP-NP asked if it would be acceptable to reestablish reactor e

criticality and then to hold in the standby mode.

(9) NRC (Wiggins) responded no and VP-NP/NRC agreement was reached that reactor restart would be deferred pending NRC concurrence .

with the restart.

(10) . NRC (Wiggins) then inquired about a non Natural Circulation Test related issue of RHR system operability that had been raised 11 2______-___

)

NHY MANAGMENT EFFECTIVENESS CHRONOLOGY l l

E 1 4'

during the course of an on-going NRC Engineering / Technical

. Support inspection being conducted by NRC Inspector Privedy (Inspection Report 89-08). The VP-NP replied that he was not fully briefed on the issue. The NRC SRI (Dudley) replied that he was following the issue, that the NHY Manager of Engineering had been apprised of the issue and NRC (Wiggins) agreed to leave the 1 issue resolution.to the NRC Inspector (Privedy), the NRC SRI

.. (Dudley) and the NHY Manager of Engineering for the time being.

[The RHR operability issue was satisfactorily closed the'next day after obtaining preliminary Westinghouse input. The Manager of Engineering further advised the NRC that a final evaluation would be issued in accordance with NHY Engineering procedures.]

1800 -- .The Startup Manager, Reactor Engineering Department Supervisor and Shift Test Director answered a number of NRC Inspector I.Trapp) questions regarding:

(1) Reactor power level behavior during the transient (started at 32 F.P., decreased to a minimum of about 2% F.P. and returned to

.approximately 2.5% F.P. always remaining below the initial 31 F.P.

initial value).

(2) PORV setpoints (2385 PSIG).

l l

(3) Time duration for PORV opening (did not occur).

1 (4) Cold water reactivity excursion (the Isothermal Temperature Coefficient was pre-conditioned to be weak to the point that this l was of minor effect).

l' 1

(5) PZR low level trip setpoint (not used on 4 loop Westinghouse plants of Seabrook design).

(6) PZR high pressure trip setpoint (same as PORV setpoint).

12

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t_________

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'I NHY MANAGMENT EFFECTIVENESS CHRONOLOGY l

l J

(7) .GETARS tracings.

~

l (8) Operations Command and Control Policy (OPMM Chapter 1. Paragraph j l

2.3.1).

(9) Startup authority versus USS authority (USS, as delegated by the j SS, has overall plant operation authority).

i Approx.  !

'1830 -- After the phone call, the VP-NP, Station Manager, Assistant Station Manager, Operations Manager and Manager of Operational Support continued with their action determinations:

. (1) Determine if 1-ST-22 procedural guidance was correct.

(2) Determine where the NHY procedural adherence direction was j inadequate and determine what conceptually must change.

(3) Continue to assess the cause of the event and establish measures to prevent recurrence.

l 1830 -- The Startup Shift Test Director, Startup Manager, and the Reactor Engineering Department Supervisor convened a meeting to gather data and further determine NHY answers to NRC Inspecto: (Trapp) requests.

1845 -- The Startup Manager informed VP-NP of the NRC Inspector (Trapp) request for access to post trip information. The Startup Manager, in turn, informed Trapp of Operations post trip review procedure package availability in the Operations Manager's office.

1930 -- The Operations Manager located the NRC Inspector (Trapp) and informed him that the Operations post trip review package had been completed and ,

I 13

i NHY MANAGHENT EITECTIVENESS CHRONOLOGY 1

was available in the Operat. ions Manager's office for review'.- The NRC Inspector indicated that he would wait until the fcilowing AM to

, review.

-Approx.

.2100?-- VP-NP adjourned the discussions held in his office (Ref. 1830' entry) having achieved the following consensus positions:

-(1). The 1-ST-22 guidance was not improper and a 17% decreasing'P2R-

level.was an appropriate trip setpoint that would remain in the procedure.

(2) The USS was in error for not ordering a Reactor Trip at 17f P2R

' level decreasing.

-(3)' The need.for stronger NHY policy and direction regarding procedural adherence during plant transient conditions was agreed-upon and all present were asked to consider the discussed options-in preparation for the next day's telecon with the'NRC (Wiggins) at 0730.

Approx.

2315 -- After having arrived home from Washington DC, the President and CEO phoned the VP-NP for a status report. The VP-NP provided a brief f

{

summary of the 1800 conference call with the NRC Region I (Wiggins) making the following points:

l

-- The NRC "seemed to be pretty well satisfied" with the NHY explanation of the details of the event.

-- A couple of hardware corrective actions and some relatively minor procedure changes needed to be taken care of, but once these were concurred with by the NRC, the plant should be ready for restart.

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NHY "N"Y EFFECTIVENESS CHRONOLOGY I

-- NHY hav. committed to review with the NRC, its corrective actions associated with policy improvements on procedure compliance. .

.I NHY.had committed to review with the NRC, its schedule for completion

'of hardware corrective actions such as the corrective maintenance being performed on the steam dump valve that had malfunctioned during the test.

- Another conference call with NRC Region I had been scheduled for 0730 Friday morning to review these items.

The VP-NP then spent a few minutes focusing on the procedure compliance issue and reviewed the NHY management group's proposed position that had been developed following the 1800 conference call with the NRC.

The President and CEO indicated that he would participate in the 0730 conference call on Friday.

NOTE: .The President and CEO was not made aware, either during this briefing or during the next morning's 0645 pre-NRC telecon briefing, of a number of key facts associated with the 1800 NHY/NRC telecons i.e. the defense of operator actions taken or not taken, the suggestion that the operator actions were more i conservative than strictly adhering to a test procedure, the possibility that the NHY procedure compliance policy was essentially adequate as written and the proposal that reactor j restart be allowed to occur in parallel with NRC/NHY event evaluation conclusions and corrective action determinations.

Friday - June 23. 1989 0645 -- VP-NP pre-briefing session.

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NHY MANAGNENY EFFECTIVENESS CHRONOLOGY g

i

Participants:

President and CEO (Part-Time)

Vice President - Nuclear Production Station Manager Assistant Station Manager Operations Manager Assistant Operations Manager Manager of Operational Support Proposed rewo'rding of NHY Policy and Direction regarding procedural adherence was agreed upon.

Briefing on plant status-from Station Manager.

President and CEO concerns were expressed regarding the magnitude

-of the NRC response and how to conduct the telecon in a manner thst would'successfully identify all issues that needed to be resolved by NHY.

0700 -- The NHY NRC Coordinator was asked by NRC Inspector (Trapp) to provide the Operations Post Trip Review data package. The Operations Manager was contacted in the VP-NP's office. He informed the NHY NRC Coordinator that the data package was still available for NRC review in the Operations Manager's office.

0730 -- VP-NP established telecon with NRC Projects Branch Chief (Wiggins).

Participants:

President and CEO Vice President - Nuclear Production Station Manager Assistant Station Manager Operations Manager Assistant Operations Manager l

16 i

l l . _ _ _ _ _ _ _ _ _ _ - - - - . - - _ - - _ - l

NHY " " N EFFECTIVENESS CHRONOLOGY Manager of Operational Support J. Wiggins ---NRC Projects Branch Chief D. Havercamp -- NRC Projects Section Chief.

N. Dudley -- NRC Senior Resident Inspector-

-- (1) Other NRC Individual At The NRC Region 1 Offices (1) With respect to 1-ST-22 procedural trip limits:

Procedure was determined to be adequate and trip' limits would remain as they presently existed.

(2)- With respect to procedural compliance:

For static situations, existing NHY guidance was considered to be adequate.

l

• For transient conditions, there is a need to avoid blind, verbatim compliance. NHY personnel, particularly operators, .l are expected to follow procedures and they know that they l must be right if they choose to deviate from a procedure in 1

an attempt to preserve the safety of personnel or equipment. )

NHY management had concluded that the existing procedure direction and policy statements were too flexible for the transient condition and would strengthen the direction by revising the procedure adherence guidance to read as follows:

a 17 I

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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . __._____m______ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ . - - _ _ m- _ _ _ _ . _ _ _ . - _ _ _ _ . - - . - _ _ _ _ - - _ _-

7

't r~

NHY MANAGMENT EFFECTIVENESS CHRONOLOGY 1.5- PROCEDURE ADHERENCE 1.5.1 Policy

1. Seabrook Station maintains reviewed an'd approved procedures to govern certain processes and-

, work' activities.- Where a procedure exists, it:

shall be considered direction regarding the method' of performing the function.

2. Procedures shall be followed,'but not without question. -Where the procedure directs an action contrary to what is considered proper,' questior ,

that procedure and seek resolution with appropriate supervisory personnel. A procedure being.

questioned should not be deviated from on the basis that it is being questioned. The resolution, through appropriate supervision, shall determine ~

the proper course of action in accordance with'the requirements of procedures SM 6.1 and SH 6.2..

3. In circumstances where time does not permit following the guidance in 2. above,'the procedure shall be followed unless there'is'a compelling.

reason for the deviation.

> 4. Forms are used in the execution of procedures to record pertinent information.-1 Blanks provided on forms should be filled in with either.the data requested or "N/A" (Not applicable) as appropriate.

Large areas or large numbers of blanks'may be filled in with "N/A" and arrows if each item is not applicable to the circumstance.

5. Vendor supplied manuals / documents are to be used as reference only and not in lieu of a step by step procedure. -If such use is required, the manual / document must have the same review, approval-and control as an equivalent procedure. Excerpts from vendor manuals may be used as defined in SSMA.

1 i

(3) With respect to preventing recurrence of an operator violation of l a test procedure limit, NHY would take the following corrective actions:

(a) Revise and implement the procedure adherence policy within two weeks. ,

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i a

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NHY MANAGHENT EFFECTIVENESS CHRONOLOGY i

(b). Review and confirm hard limits'for test / procedures prior to r next.use.

! b-(c) . Station Manager would brief each operating crew prior to their return to their next shift.

l g

(d) NHY would conduct _further operator classroom and simulator

' training on these issues, on an on-going basis.

(4) With' respect to restart impediments and schedule, NHY committed to:

(a) Resolve the Main Steam Dump Valve operability problem.

(b) Resolve the MSIV "D" air maintenance pump sticking pilot valve problem.

(c) Resolve the RHR operability issue, t:

l (5) When, questioned, the VP-NP felt that NHY readiness to restart might be possible by. late morning but not before 1030.

(6) The NRC (Wiggins) had no further questions at that time, expressed the need to talk further with his management, committed to get l

back to NHY (VP-NP) prior to 1000,. understood the NHY responses provided and asked that restart not occur until after his return call.

l 1000 --- The Station Manager informed the Startup Manager that restart of plant and conduct of 1.ST-22 would slip to 0700, June 24, 1989 at the earliest, in order to ensure that all NRC concerns and NHY actions were resolved prior to restart.

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NHY MANAGMENT EFFECTIVENESS CHRONOLOGY Approx.

1030_-- The VP-NP called NRC (Wiggina) to inform him that the NHY target for restart readiness had beeri changed to Saturday, June 24, 1989, 0700.

Wiggins acknowledged and indicated that his management had not gotten back to him regarding the earlier (0730 to 0810) telecon.

1100 -- (2) NRC exits occurred in Room 245 in the Station:

NRC Inspector (P:ivedy) IR 89-08.

NRC Inspector (Trapp)

Potential violation regarding operator procedural adherence during 1-ST-22 Natural Circulation test conduct. Further investigation of the occurrence would occur.

1140 - - NHY/NRC meeting following NRC erits:

Participants:

Vice President, Engineering, Licensing and Quality Programs Station Manager NHY NRC Coordinator D. Havercamp -- NRC Projects Section Chief N. Dudley -- NRC Senior Resident Inspector ,

The NRC made clear that they felt the Reactor should have been tripped in accordance with 1-ST-22 criteria.

The NRC expressed that the NHY Operations and Test personnel response to NRC inquiries, during the course of the event, was inappropriate.

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' ' ' -- __ --_-_,__________________________m_ _ _ _

)

1

~1 NHY MtJEAGMENT EFFECTIVENESS CHRONOLOGY 1

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• The NRC was concerned over their impression that NHY was preparing j to restart without giving full consideration to the event and its' implications / seriousness.

The NRC indicated that some wrong information appeared to have been passed to the Region and Washington and that.the NRC was trying to correct that situation.

NHY advised the NRC that procedure adherence philosophy is to strictly follow procedures unless compelling circumstances exist to the contrary. I l

NHY advised the NRC that the event scenario.and the restart l criteria would be discussed at the Self Assessment Team / Management Oversight Committee meeting scheduled for 1200, June 23, 1989.

1140.-- The VP-NP called the Station Manager's office to speak with the NRC f 4

Projects Section Chief (Havercamp) and the NRC Senior Resident j Inspector (Dudley) with respect to a NHY press release. The VP-NP l expressed that with the heightened media attention surrounding this event. NHY was considering the formulation of a press release to {

address the operator procedural non-compliance issue and the NRC on- l going evaluation of a potential violation. Specifically, the question i was whether the NRC, if asked by the media, would feel obligated to respond that a violation had been issued or would they respond that a potential violation was being ovaluated. The NRC individuals could not answer with certainty at that moment. Therefore, the VP-NP informed the NRC that NHY would probably issue a press release and that the NRC

]

would be provided a copy immediately upon issuance in order to keep the NRC fully informed. i 1200 -- The Assistant Operations Manager informed the on-shift Shift Superintendent that the Station Manager would address each shift of operators with respect to procedure adherence. The Shift Superintendent was also requested to start making plant preparations l 21

_ _ _ _ _ _ _ _ _ __ J

(

NHY MANAGMENT EITECTIVENESS CHRONOLOGY t

for. Turbine Torsional testing since the 1-ST-22 Natural Circulation test would be deferred until all NRC and NHY concerns were fully resolved.

1200 -- The Operations Manager provided the NRC Inspector (Trapp) with Main. j 1

Plant Computer System alarm summary log. J 1230 --- The VP-E.LEQP briefed the President and CEO and the VP-NP on the 1140 meeting with the NRC.

The President and CEO, VP-E L&QP, VP-NP, Station Manager and Corporate

~ Communications Staff prepared a NHY press release to address the procedure non-compliance and potential NRC violation issue.

l.

1250 -- The Self Assessmen,t Team (SAT) - Management Oversight Committee (MOC) meeting convened in accordance with a commitment made earlier in the week.

Participants:

President and CEO Vice President, Engineering, Licensing and Quality Programs Vice President - Nuclear Production Station Manager Independent Review Team Representative 1

)

(Acting SAT Manager) I Manager of Operational Support - SAT Member g Production Services Manager - SAT Member Previously scheduled agendas (1) SAT Special Event Analysis of (9) Operations and Maintenance events.

(2) SAT verbal ' Readiness To Cooldown' report.

22

_ _ _ _ _ _ _ _ _ _ _ _ _ _ -. 1

NHY MANAGMENT EFFECTIVENESS CHRONOLOGY Additional agendas (1) SAT actions taken to follow the organizational response to the 1-ST-22 event.  ;

(2) June 22, 1500, post-trip critique in the Technical Support Center, (3) Corrective actions that would be necessary to assure strict adherence to procedures.

(4) Restart constraints and approval of restart prerequisites.

The Production Services Manager was in the Control Room, as an SAT evaluator, during the course of the event.

The Hanager of Operational Support, as the on-duty SED, responded in accordance with NHY Procedure 12830. Per the Station Manager's request, he established the Event Evaluation Team (EET) composition and participated as an EET member.

The IRT Representative had been assigned SAT evaluation management responsibilities by the SAT Manager as of 1430, June 22, 19P*.

1345 -- NRC Projects Section Chief (Havercamp) telecon to VP-:1P in response to their 1140 discussion. Because the potential violation occurred during this evaluation period, the on-going evaluation would remain open pending final determination by Region management.

1350 -- The NRC Deputy Region Administrator (Martin) telecon to the NHY President and CEO occurred:

• The NEY June 22, 1989, Natural Circulation Test event had been cause for wide agency review and concern within the NRC.

23

NHY MANAGMENT EFFECTIVENESS CHRONOLOGY  ;

• The NRC was disturbed about the specified 17% PZR low level trip criteria not being adhered to.

The NRC had informed (3) NHY individuals that the test was outside of specified ' trip criteria, during the course of the event, and the NHY response was inadequate. ,

The anticipated NHY actions prior to restart were as follows:

(1) Complete and document the post trip review process.

(2) Short term corrective actions:

resolve failure to follow procedures

' resolve failure of management to intercede

• resolve failure of senior management to take appropriate and aggressive follow-up action (3) Longer term corrective actions:

address potentially broader implications

• establish schedules for implementation

• The results of the NHY actions would be reviewed with the NRC staff and the agreement of the Regional Administrator would be obtained prior to restart.

What NHY had proposed to the NRC Projects Branch Chief was inappropriate.

An NRC Inspection Team would be placed on site to conduct an NRC inspection and provide a report on the event. When asked if this was to be an Augmented Inspection Team, the NRC responded no.

That this NRC inspection would be principally comprised of the 24

NHY MANAGMENT EFFECTIVENESS CHRONOLOGY Resident Inspector and those low power testing observation inspectors already on site.

1400 -- The Shift Test Director provided GETARS traces to the NRC Senior Resident Inspector (Dudley). I l

1430 -- The NRC Projects Section Chief (Havercamp), NRC Senior Resident  ;

Inspector (Dudley) and NRC Inspector (Trapp) r6 quested a briefing on the SAT /MOC meeting that had been conducted at 1250. The three SAT members, that had attended the MOC meeting provided the requested 1

briefing covering the issues noted in the 1250 entry above. Additional discussion occurred associated with the following issues:

(1) MOC restart constraints from the SAT perspective.

(2) SAT members perspective on the NHY procedure compliance philosophy, the failure to follow procedures during the event and the NHY corrective actions being considered to strengthen ,

procedure compliance.

(3) Procedure change details considered to be required prior to restart.

The NRC expressed'that absent the procedure non-compliance occurrence, the operator's attention and actions taken with regard to the technical aspects of the plant were good. However, when the procedure non-compliance issue was brought into consideration, the NRC had concerns with respect to (1) NHY management actions proposed prior to restart.

(2) NHY management actions not taken during the event.

(3) The existing NHY command and control philosophy.

25

NHY MANAGMENT EFFECTIVENESS CHRONOLOGY

-1430 -- The VP-NP, VP-E.L,&QP, Station Manager and the Shift Test Director met to develop a plan and to establish a preliminary schedule for responding to Confirmatory Action Letter (CAL) 89-11. Four parallel efforts were initiated:

(1) The combined Shift Test Director and Event Evaluation Team Leader was directed to complete the NHY 12810 and 12830 event evaluation / root cause analysis report.

(2) The Operations Training Manager was directed to conduct a human factors / human performance review, through a series of operator interviews, and to develop a report and set of recommendations based on the input and conclusions for his review.

(3) The Independent Review Team (IRT) was directed to conduct a management effectiveness evaluation, through a series of management interviews and through an assessment of existing NHY policy focused principally within the following three policy areas:

• Command and Control

• Procedure Compliance

• Post-Trip Reviews The IRT was directed to develop a report and set of recommendations based on the assessed performance of the NHY management team involved and the IRT assessment of existing policies.

(4) The Operational Programs Manager was directed to coordinate these three efforts and reports into a single document that would become the basis for the NHY Management's response to CAL 89-11.

26  :

NHY MANAGMENT KFFECTIVIDfESS CHRONOLOGY A June 24, 1989, 1000 meeting was scheduled .o ensure agreement on scope, format and to. propose a completion schedule.

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