United States Nuclear Regulatory Commission - Protecting People and the Environment

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
.

                                                            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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