Information Notice No. 90-54: Summary of Requalification Program Deficiencies
UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR REACTOR REGULATION
WASHINGTON, D.C. 20555
August 28, 1990
Information Notice No. 90-54: SUMMARY OF REQUALIFICATION PROGRAM
DEFICIENCIES
Addressees:
All holders of operating licenses or construction permits for nuclear power
reactors.
Purpose:
This information notice alerts addressees to problems identified during
administration of the NRC's licensed operator requalification examination
program. The problems and weaknesses summarized herein were compiled from
NRC examination reports issued to facilities that received unsatisfactory
requalification program evaluations or exhibited significant weaknesses
during the examination process. It is expected that recipients will review
the information for applicability to their facilities and consider actions,
as appropriate, to avoid similar problems. However, suggestions contained
in this information notice do not constitute NRC requirements; therefore, no
specific action or written response is required.
Description of Circumstances:
All facility licensees are required by Section 50.54(i) of Title 10 of the
Code of Federal Regulations (10 CFR) to implement an operator
requalification program that must, as a minimum, meet the requirements of 10
CFR 55.59. Pursuant to 10 CFR 55.57(b), an operator's license will be
renewed if the Commission finds that the operator has successfully completed
an approved requalification program as required by Section 55.59 and, among
other things, has passed a comprehensive requalification written examination
and operating test administered by the Commission during the term of his or
her 6-year license.
In November 1988, the NRC implemented the requalification examination
program, as described in ES-601 of Revision 5 of NUREG-1021, "Operator
Licensing Examiner Standards." The requirements and procedures contained
therein were derived based on a Systems Approach to Training (SAT) program
and rely on existing requalification program standards for guiding the
development and implementation of NRC examinations. The program evaluates
the effectiveness with which the facilities' requalification training
programs enable licensed operators to maintain their competency and currency
while providing individual operators the opportunity to satisfy their
regulatory requirement to pass an NRC requalification examination before
license renewal.
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The NRC-administered requalification examination is composed of a
comprehensive operating test and a written examination developed by a team
of NRC examiners and facility representatives. The two-phase operating test
(crew evaluation on a dynamic simulator and individual evaluation using Job
Performance Measures (JPMs)) and the two-section, open-reference written
examination (static simulator and classroom) are, to the extent practical,
based upon the facility's requalification program and its learning
objectives.
Of the 79 facilities evaluated against the criteria in ES-601 (Revision 5),
10 programs exhibited deficiencies warranting an overall unsatisfactory
program rating. Table 1 (Attachment 1) identifies those facilities, the
reasons their programs were determined to be unsatisfactory, and whether or
not their requalification programs had received separate INPO accreditation
before the NRC examination.
The following is a description of generic weaknesses found during the
requalification examinations. The findings have been organized into two
categories: "Safety and Technical" and "Program."
Safety and Technical Weaknesses
Communications: Several crews communicated poorly during the dynamic
simulator portion of the examination.
At Brunswick, the crews had difficulty maintaining reactor vessel level
within the required range because the panel operators failed to keep their
supervisors informed of vessel levels and injection system status. At
Limerick, the panel operators communicated vital plant information
simultaneously, creating confusion for their supervisor. The operators
failed to coordinate and prioritize critical plant parameters, which
compounded the communications problems in the control room.
At Ginna, operators failed to acknowledge orders from shift supervisors or
inconsistently informed them of task completion, thereby complicating
recovery efforts.
Senior Reactor Operator (SRO) Command and Control: Many SROs demonstrated
weakness in their command and control. These deficiencies included an
inability to define and prioritize problems, inconsistent assignment of task
responsibilities between shift supervisors and shift foremen, and a lack of
direction and leadership of the crew.
At Limerick, there was a general lack of coordination among the operators in
the control room. Shift supervisors did not keep the crew informed of plant
recovery progress, nor did they give specific task instructions to the crew
when required. When the situation required that operators perform
concurrent action steps from the emergency operating procedures (EOPs), the
shift supervisors had difficulty establishing priorities. At Nine Mile
Point 2, shift supervisors were unable to prioritize operator actions,
provide specific guidance to operators, or keep the crew apprised of plant
status and recovery actions. Crews consistently allowed reactor vessel
level limits to be exceeded because
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supervisors and operators were distracted by less important tasks. At
Brunswick, three of the four evaluated crews lost control of major plant
parameters. During an anticipated transient without scram (ATWS) scenario,
two crews failed to control coolant injection systems, allowing cold,
unborated water to be added to the vessel at excessive rates causing
unacceptable power increases. Command and control problems at Brunswick
were intensified by deficiencies in communication and EOP usage.
At Millstone 3, examiners observed that both the Shift Supervisor (SS) and
the Senior Control Operator (SCO) were directing the crew. The directions
were not coordinated, giving the impression that neither supervisor was in
charge. In one scenario, the SS was so involved in responding to minor
alarms that he lost perspective of overall plant status.
Use of Emergency Operating Procedures: Several crews exhibited major
weaknesses in using EOPs. Deficiencies included the inability to perform
critical steps in a timely manner or in their proper sequence, the inability
to use flowcharts, and the inability to recognize EOP entry conditions.
At Limerick, many operators were unaware of or exhibited weakness in the
execution of time-critical steps in the EOPs. Several operators were
unaware of the initiation of the timer for the Automatic Depressurization
System (ADS). At the time required, the operators did not perform other time
or parameter-dependent steps, such as spraying the suppression pool. At
Nine Mile Point 2, operators violated the EOPs by securing Standby Liquid
Control System pumps during an ATWS before the exit condition for that EOP
was satisfied. The operators also had difficulty performing immediate
emergency actions without referring to the procedure and did not maintain
compliance with the EOPs when trying to perform actions from memory. At
Brunswick, operators misread the EOP flowcharts and lowered reactor vessel
level during an ATWS, even though a heat sink was available and the torus
temperature did not mandate those actions. Oyster Creek's program was
evaluated as satisfactory, but many operators displayed weaknesses
identifying critical plant parameters and indications requiring entry into
the EOPs.
At Millstone 3, a crew violated the requirements in the owners' guide of the
Westinghouse Owners Group when it incorrectly proceeded from one EOP into
another while executing a Functional Restoration Procedure (FRP). Eight
operators at Millstone 3 also failed JPMs requiring them to implement a
sequence of steps from the EOPs from memory (to verify that all dilution
paths were isolated). At Turkey Point, operators frequently waited until
the Assistant Plant Supervisor Nuclear entered the EOPs and began reading
the immediate action steps aloud before they executed them. The resultant
delay in performing the immediate action steps complicated the operators'
recovery efforts. At Point Beach, several EOP transition steps, which
required the Duty Operations Supervisor to make decisions based upon trends
in vital plant parameters, were performed incorrectly. Additionally, some
operators omitted steps when they attempted to perform immediate emergency
actions from memory. An SRO subsequently identified these errors while
making the checks for procedure step completion.
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Technical Specification Interpretation and Usage: Several crews had
difficulty in either recognizing or interpreting the limiting conditions for
operation (LC0) stated in the Technical Specifications. At some facilities,
interpretation documents were available in the control room, but operators
were unable to use them.
At Nine Mile Point 2, operators were given scenarios requiring them to
interpret Technical Specifications. In some cases, the operators were
unable to properly interpret the LCO themselves. In other cases, the
operators were unable to correctly interpret facility guideline documents.
At Millstone 3, the senior shift supervisor acknowledged the loss of a power
range nuclear instrument, but never consulted the Technical Specifications
for the required action and LCO.
Operation of Emergency Core Cooling Systems (ECCS): Deficiencies in this
area involved the misoperation of controllers, incorrect verification of
injection status, incorrect verification of reactor vessel level with ECCS
injecting, and lack of general knowledge of the system and associated
interlocks.
At Brunswick, some operators were unable to properly shut down the turbine
in the High Pressure Coolant Injection System when required. Other
operators were unable to place the Residual Heat Removal System in torus
cooling mode because they did not understand the operation of system
interlocks. The operators were also unable to determine whether drywell
sprays should be initiated. At Nine Mile Point 2, operators had difficulty
maintaining reactor vessel level within acceptable bands during emergencies
and verifying whether all available ECCS systems were injecting. At
Limerick, some operators could not operate ECCS equipment in accordance with
the procedure when required to do so from memory, and others left the ECCS
equipment running unattended in the manual mode of operation.
Emergency Action Level Classification: At Nine Mile Point 2, several SROs
had difficulty determining the appropriate emergency action level (EAL)
during the dynamic simulator portion of the examination. SROs at Limerick
had difficulty classifying a fuel handling event on the written portion of
the examination.
At Turkey Point, shift supervisors neglected shift operations and
communications while implementing the emergency plan. Plant conditions
subsequently deteriorated beyond the EAL in effect without the supervisor's
knowledge.
Program Weaknesses
Facility Evaluators: Several evaluators did not meet the performance
guidelines established in NUREG-1021.
At Browns Ferry, one evaluator interrupted the operator to ask knowledge
questions during the performance of a JPM, was inattentive to the operator's
actions requiring the operator to repeat steps, and prompted the operator
during the performance of critical steps. For example, the evaluator turned
on area lighting, found local procedures, and asked leading questions.
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Some evaluators at Turkey Point were unfamiliar with the location and
general content of the JPMs they were to administer. Other evaluators led
the operators to the location for performing the JPM instead of having the
operator locate the area as part of the examination, or they asked questions
that were unrelated to the JPM or system that was being examined.
Shift Staffing and Rotation: The ability of some crews to execute the
emergency operating procedures changed dramatically depending on which SRO
on the crew was rotated into the shift supervisor position. It is important
that each senior operator be capable of directing these procedures.
At Browns Ferry, the Shift Operating Supervisor (SOS) and the Assistant
Shift Operating Supervisor (ASOS) were both trained to direct and implement
the EOPs. However, the examiners noted that personnel normally assigned to
the SOS position were generally weak in this area.
At Point Beach, crews made several errors in implementing the EOPs when the
Duty Shift Supervisor rotated down to the Duty Operations Supervisor's
position and had to direct the performance of the EOPs.
Reference and Examination Material: Several facilities had poor quality
reference and examination materials (simulator scenarios, JPMs, and written
test items). The exam team had to upgrade the material so that it met
minimum standards for exam administration.
At Turkey Point, the JPMs had not been verified against plant procedures.
This created difficulties when evaluating the operators because some
critical procedural steps had been omitted from the JPMs. Additionally,
simulator scenarios developed to train the operators did not challenge the
operators' analytical abilities during major plant transients.
Consequently, the operators had difficulty responding to the more complex
examination scenarios. At Zion, the deficiencies in reference and
examination material included placing direct "look-up" questions on the
written examination, fewer than the required number of transients and
failures in the "static simulator" section of the written examination,
ambiguously worded questions, trick questions, JPMs designed to be
administered in the plant (instead of on the simulator), excessive
duplication among dynamic simulator scenarios, and scenarios with illogical
or unrelated malfunctions.
Procedure Control: Several facilities did not maintain current copies of
controlled procedures in the simulator or allowed crews to use unauthorized
procedures and references. When errors were discovered and the incorrect
procedures replaced, the operators had difficulty using the correct
procedures.
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At Ginna, the EOPs were revised to eliminate earlier problems with operator
confusion, and training on the new procedures was initiated but not
completed before the examination. Consequently, when the older EOPs were
used during the examination, they caused even more confusion and poor
operator performance. At Turkey Point, the operators used a document in the
simulator which was not controlled or authorized for use in the control
room.
Discussion:
As noted earlier, specific evaluation guidelines for the requalification
program are provided in NUREG-1021. It is important to note that the
generic deficiencies described herein were identified during NRC
requalification program evaluations and may provide some insight into the
adequacy of addressees' requalification programs developed to meet the
guidelines established in NUREG-1021.
In addition to the generic deficiencies described herein, the NRC cautions
addressees not to focus their simulator training programs exclusively on low
probability, catastrophic failures. Although the NRC simulator
requalification examination concentrates on the use of emergency operating
procedures and the emergency plan, it is important that licensees also
provide their operators with simulator training on abnormal events and
transients of higher probability. At several facilities, NRC examiners
noted this tendency to design the operator training program around the NRC's
examination requirements. The NRC is concerned that the operators may lose
the ability to respond to abnormal events particularly during extended
periods of steady state operation.
This information notice requires no specific action or written response. If
you have any questions about the information in this notice, please contact
one of the technical contacts listed below or the appropriate NRR project
manager.
Charles E. Rossi, Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical D. J. Lange, NRR T. A. Peebles, RII J. L. Pellet, RIV
Contacts: (301) 492-3171 (404) 331-5541 (817) 860-8159
R. M. Gallo, RI G. C. Wright, RIII D. F. Kirsch, RV
(215) 337-5291 (708) 790-5695 (415) 943-3723
Attachments:
1. Table 1
2. List of Recently Issued NRC Information Notices
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Attachment 1
IN 90-54
August 28, 1990
Table 1
REQUALIFICATION
FACILITY EXAM DATE PROGRAM FAILURE MODE INPO ACCREDITED
BROWNS FERRY 7/89 (2) NO
BRUNSWICK 5/90 (2), (3) YES
DUANNE ARNOLD 6/90 (3) NO
GINNA 6/89 (2) NO
LIMERICK 1/90 (2) NO
MILLSTONE 3 9/89 (2), (1), (5), (4) NO
NINE MILE POINT 2 7/89 (2), (5) NO
POINT BEACH 2/89 (2) NO
TURKEY POINT 3/89 (2), (3), (7), * NO
ZION 9/89 (2), (5) NO
PROGRAM FAILURE MODES:
(1) 90% PASS/FAIL GRADING AGREEMENT BETWEEN FACILITY/NRC CO-EVALUATORS
(2) 25% OF OPERATORS FAIL AT LEAST ONE PART OF THE EXAM
(3) 1/3 OF CREWS FAIL SIMULATOR PORTION OF THE EXAM
(4) 50% OF OPERATORS FAIL THE SAME COMMON JPM
(5) 50% OF OPERATORS FAIL THE SAME COMMON JPM FOLLOW-UP QUESTION
(6) 25% OF OPERATORS ANSWERED AT LEAST 20% OF JPM FOLLOW-UP
QUESTIONS INCORRECTLY
(7) 1 EVALUATOR DETERMINED TO BE UNSATISFACTORY
* FACILITY DID NOT TRAIN/EVALUATE SROs IN ALL LICENSED POSITIONS.
FACILITY DID NOT HAVE AN IN-PLANT JPM PROGRAM.
.ENDEND
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