GO2-91-171, Provides Critical Evaluation Re Failures of Crew D During Annual Requalification Exam Administered on 910909. Contributing Factors Included,Insufficient Performance Overlap Amongst Crew Members & Training Evaluation Process

Provides Critical Evaluation Re Failures of Crew D During Annual Requalification Exam Administered on 910909. Contributing Factors Included,Insufficient Performance Overlap Amongst Crew Members & Training Evaluation Process

ML17286B107
Person / Time
Site:	Columbia
Issue date:	09/20/1991
From:	Oxsen A WASHINGTON PUBLIC POWER SUPPLY SYSTEM
To:	Martin J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
References
GO2-91-171, NUDOCS 9110250063
Download: ML17286B107 (9)

Text

ACCELERATED DISTRIBUTION DEMONSTRATION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9110250063 DOC.DATE: 91/09/20 NOTARIZED:

NO DOCKET FACIL:50-397 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH.NAME AUTHOR AFFILIATION OXSEN,A.L.

Washington Public Power Supply System RECIP.NAME RECIPIENT AFFILIATION IIARTIN,J.D.

Region 5 (Post 820201)

SUBJECT:

Provides critical evaluation re failures of Crew D during annual requalification exam administered on 910909.

Contributing factors included, insufficient performance overlap amongst crew members 6 training evaluation process.

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WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968

~ 3000 George Washington Way

~ Richland, Washington 99352 September 20, 1991 602-91-171 Docket No. 50-397 J. D. Martin, Regional Administrator U.S. Nuclear Regulatory Commission Region V 1450 Maria Lane, Suite 210 Walnut Creek, CA 94596

Dear Mr. Martin:

l.iI CO

[~s i ti

Subject:

NUCLEAR PLANT NO. 2, OPERATING LICENSE NPF-21 MANAGEMENTEVALUATIONOF THE SEPTEMBER 9, 1991 CREW D EXAMFAILURE On September 9, 1991, the Supply System administered an annual requalification exam to Crew D.

The results were that three individuals failed and that the crew failed.

This letter is to provide our critical evaluation of why the failures occurred and to describe what the Supply System is doing to correct the identified weaknesses.

This evaluation was conducted by Mr.

Jack Baker (WNP-2 Plant Manager) and Mr. Dave Kobus (Technical Training Manager) with an independent validation by a designated Root Cause Team from our Licensing and Assurance directorate.

These issues were verbally discussed with Region V and NRR during a telephone conference call on September 18, 1991.

The causal factors for the Crew D failure along with a corrective action plan/schedule are included in Attachment 1.

There are three major themes that emerge from our evaluation of why the failure occurred.

The'irst factor was that there was insufficient performance overlap amongst the crew members i.e., Shift Manager, Control Room Supervisor, Shift Technical Advisor and the Reactor Operators.

An operating condition was identified by the Reactor Operators which required a response by our Emergency Operating Procedures.

This action was not immediately identified by our Control Room Supervisor nor was it identified in the next 9.5 minutes by the rest of the Control Room staff.

Our program of defense-in-depth did not occur during this scenario.

The second factor deals with our training evaluation process.

We found that our evaluation process did a reasonable job in identifying performance weakness data.

This evaluation process was used to identify "general" strengths and weaknesses of the individuals and the crew.

What was lacking was the identification of the "specific" weaknesses of the individuals and the crew such that specific training could be targeted to improve performance 9110250063 910920 PDR ADOCK 05000397 V

PDR

'. B. Martin September 20, 1991 Page Two MANAGEMENTEVALUATIONOF THE SEFIXMBER 9, 1991 CREW D EXAMFAILURE or to obtain consistent performance.

The third factor was our management decision process in assessing crew readiness for the exam and plant operation.

We did not sufficiently focus on the specific evaluation details but instead relied on a more general qualitative assessment.

These three factors directly led to our underestimation ofthe individual/crew readiness for examination and subsequent operation.

We have modified our training/evaluation process, crew structure for Crew D and management decision making process in light of these concerns.

(See Attachment 2 for our revised crew staffing.) In addition, we have determined that no additional changes to Crews B, C, E or F are required to address the "crew overlap" concern.

We asked ourselves ifwe rushed the training/evaluation process of Crew D.

The answer is definitely no.

We provided Crew D with what we believed to be adequate training/evaluation to ensure that all individuals and the crew would pass their evaluation.

Because of identified weaknesses, two delays in the exam schedule occurred to provide more training time.

Crew personnel adjustments were also made.

In hindsight, we should have done better in identifying the crew's needs and refocused our training to correct these needs.

Instead, we continued with the belief that additional scenarios would bring the crew to an acceptable state of readiness.

Crew D is currently scheduled for their next exam on September 25, 1991.

To date, their progress is good.

Their ability to perform individually and as a crew is improving. We will notify you by noon on September 23, 1991, ifwe are confident in sponsoring Crew D for an exam and subsequent operation.

Ifyou have any questions regarding the information provided in this letter, please contact me directly.

Very truly yours, A. L. Oxsen Deputy Managing Director JWB/bk Attachments CC:

Document Control Desk - NRC P. L. Eng - NRC D. L. Williams/BPA - 399 NRC Site Inspector - 901A

ATTACHMENT1 CAUSALFACTORS FOR CREW "D" FAILURE MANA EMENT I S Receptivity of the crew to critical review and commitment to accept and perform to specified standards of performance were less than adequate.

~ma:t'ritical feedback was not always applied to improve crew performance.

Crew performance was inconsistent and the management of the crew was not effective in setting standards and holding the crew members accountable for acceptable performance.

rrective Acti n Pl Operations Manager to meet with Crew D to discuss this issue.

Ensure that performance standard weaknesses identified through the evaluation process are understood and corrected by crew management and other members of the crew. Actions are in progress for Crew D and ongoing for other crews as issues are identified.

2.

The management of the crew was not expecting the Reactor Operators (ROs) to take the initiative to utilize their diagnostic abilities as part of the team.

I~mac:

The responsibility for ensuring the proper actions of the crew was vested in the Senior Reactor Operators (SROs).

Any weaknesses would not be corrected by the actions of the other members of the team, such as the

ROs, as was the case in the failed scenario.

The lack of a positive influence from a strong RO was a contributing factor. Management policy must clearly identify the expectation of the ROs.

orrective Action Plan Operations Manager to provide verbal guidance to Crew D immediately followed by a written policy by October 15, 1991, which clarifies the performance expectations of the ROs.

Training willprovide training and evaluation to ensure the diagnostic input from ROs is occurring to the proper degree prior to the upcoming exam.

3.

The Shift Technical Advisor (STA) missed an opportunity to advise crew management on the priority concern of power reduction.

~Im ac'ne key element of the STA position is to advise the crew of priority actions relating to the core.

Actions to clarify the role of the STA were in progress since the initial failure but not completed in time to effectively

Attachment 1

Page 2 of 5 influence this position as part of the team, In the scenario which was failed on September 9, 1991, the STA failed to deduce the priority concern and advise the Control Room Supervisor of the correct actions.

rrective Ac on Pl Plant Manager to issue a policy letter clarifying the performance expectations of the STA by September 23, 1991.

Training to develop and implement evaluation criteria by November 1, 1991.

Training and evaluation will be conducted prior to the upcoming exam to ensure proper STA role is being applied.

4.

Management decided to present this crew for examination without adequate knowledge of the specific details.

Although areas of weakness were noted, crew performance was improving but not consistent.

~Im act'he crew failed 3 of their final 14 scenarios.

Crew D was presented for examination without management understanding the specific weaknesses in individual and crew performance.

Corrective Action Plan A readiness review meeting, consisting of at least the Operation Training Review Board members, willbe held prior to presenting this crew for the upcoming exam. This review will focus on why the crew is ready to be put up for examination instead of a process that seeks why they are not ready.

This review willevaluate individuaUcrew scenario performance data, including trends, in detail.

5.

Management involvement was not fully effective at influencing crew and evaluator performance in the identified weakness areas.

I~mac'he contributing weakness areas in this summary should have been corrected during the conduct of training.

C rr iv Aci nPI Management involved with the determination of Crew D readiness will use the lessons learned from this report in determining Crew D readiness for the upcoming crew exam.

TRAININ I 1.

This crew had several failures in ATWS scenarios in previous training which indicates less than effective training on this particular category of events.

Attachment 1

Page 3 of 5

~Im act'he opportunity to correct any weaknesses in this category of events was available, but not identified as a need.

orrec ive Acti n Pl Assurance that practice on all critical EOP transition points must be designed into our training program.

Training staff to identify individual and Crew D weaknesses and provide training and evaluation to ensure the weaknesses are corrected prior to the upcoming exam.

By November 15,

1991, develop a process to incorporate this methodology into the training process.

2.

The crew focused more on the suspected event than on the symptoms.

~m)~g The action of the crew was focused on pressure control to facilitate maintaining feedwater from the condensate system at the expense of actions to reduce reactor power.

This type of performance is intended to be avoided and inconsistent with our symptom based EOPs.

Training must emphasize the hazards of event based preoccupation.

orrective Action Pl Training staff to identify individual and Crew D weaknesses and provide training and evaluation to ensure the weaknesses are corrected prior to the upcoming exam.

By November 15, 1991, develop a process to incorporate this methodology into the training pl'ocess.

3.

The teamwork of the crew was ineffective in the failed scenario.

~Im act:

The defense-in-depth concept requires effective teamwork.

In the failed

scenario, other members of the crew had an opportunity to correct the error committed by the Control Room Supervisor.

Role clarification and principles of effective teamwork must be emphasized to obtain consistent performance.

rr tiv A 'PI Training staff to identify individual and Crew D weaknesses and provide training and evaluation to ensure the weaknesses are corrected prior to the upcoming exam.

By November 15, 1991, develop a process to incorporate this methodology into the training process.

Attachment 1

Page 4 of 5 VAL ATI NPROC I S 1.

The evaluation process was not as effective as needed to identify and strengthen improper perform ailce.

The evaluation process should be focusing and providing feedback on all key operational practices of each scenario to reinforce the significant correct actions as well as the incorrect.

The response to this corrective action after the initial failure was not as effective as desired.

Training scenario coaching also was not as effective as desired.

orrective Action Plan Training staff to identify individual and Crew D weaknesses and provide training and evaluation to ensure the weaknesses are corrected prior to the upcoming exam.

Any weaknesses identified during our current evaluation scenarios are remediated immediately. In addition, the ability to pick out root weaknesses willbe bolstered in our evaluation of scenario performance results.

By November 15, 1991, develop a process to incorporate this methodology into the training process.

2.

Evaluation details were not adequately scrutinized to detect patterns of weak individual and team performance.

I~mac The evaluation of performance was conducted on a scenario by scenario basis by the evaluators.

Competency results were numerically tracked; however, specific individual weaknesses were not portrayed in a fashion in which specific needs could be identified.

This area was a missed opportunity to focus on these needs to improve the effectiveness of remediation activities.

orrec ive Action Plan Training staff to identify individual and Crew D weaknesses and provide training and evaluation to ensure the weaknesses are corrected prior to the upcoming exam.

By November 15, 1991, develop a process to incorporate this methodology into the training process.

3.

Post scenario questioning techniques are not always adequate to solicit the necessary responses to substantiate weaknesses.

Detailed weakness documentation is essential to formulating individually focused remediation.

Attachment 1

Page 5 of 5

~mirac Improper techniques can erroneously identify weakness or fail to identify weakness as well.

rr v

A inPln By November 15, 1991, the Technical Training Manager will develop and execute a training program for trainers/evaluators to address this issue.

R ED IS The override box on the flowchart was not utilized as intended.

The table containing the direction to go to the other leg of the ATWS chart was not noticed when needed.

~1m)~c'he override structure of the current flowcharts has been identified as a weakness and is targeted for correction in the phase II EOP upgrade effort.

orrective Acti n Plan Training willemphasize the crews awareness of non-conventional overrides prior to the upcoming exams.

The Operations Manager willdetermine the necessity to take similar actions for the other crews. This override structure willbe corrected in the phase IIEOP upgrade program.

Page 1 of 1 ATTACHMPKF2 Becker Rockey Rambo Gallagher TBD CREW A CREW B Mann Langdon Zimmerman Henderson Baird Strote Hen drick TBD TBD CREW C CREW D CREW E CREW F Kozlik Taylor Prescott Moore Zlatnik Woods Green Lambel Hughes Gregory Nelson Westergard Ramos Herrington Villarruel Powers Kleven Weaver Hlavaty Berglund Dixon