Information Notice No. 86-64, Supplement 1: Deficiencies in Upgrade Programs for Plant Emergency Operating Procedures

                                                     SSINS No.: 6835       
                                                     IN 86-64, Supplement 1 

                                UNITED STATES
                        NUCLEAR REGULATORY COMMISSION
                    OFFICE OF NUCLEAR REACTOR REGULATION
                           WASHINGTON, D.C. 20555

                               April 20, 1987

Information Notice No. 86-64, Supplement 1:   DEFICIENCIES IN UPGRADE 
                                                  PROGRAMS FOR PLANT 
                                                  EMERGENCY OPERATING 
                                                  PROCEDURES 

Addressees: 

All nuclear power reactor facilities holding a construction permit (CP) or 
an operating license (OL). 

Purpose: 

This notice is to alert recipients to significant problems that are 
continuing with plant emergency operating procedures (EOPs). Although a 
previous Information Notice was issued on this subject, indications are that
many utilities continue to inadequately develop and implement upgraded EOPs 
and are failing to meet commitments made to the NRC. Deficiencies continue 
to be identified in all the major aspects of utility EOP upgrade programs. 

It is expected that recipients will review this information for 
applicability to their facility and consider actions, if appropriate, to 
correct or preclude similar problems occurring at their facilities. However, 
suggestions contained in this notice do not constitute NRC requirements; 
therefore, no specific action or written response is required. 

Background: 

Information Notice No. 86-64, "Deficiencies in Upgrade Programs for Plant 
Emergency Operating Procedures," was issued on August 14, 1986. The 
Information Notice described the results of four audits of emergency 
operating procedures implementation. Based upon the deficiencies identified 
by those audits, the staff concluded that other utilities may not have 
appropriately developed and implemented upgraded EOPs in accordance with 
their commitments based on NUREG-0737, Supplement 1, Requirements for 
Emergency Response Capability. 

In that Information Notice, the staff stated that it would continue audits 
to determine the scope and safety significance of the deficiencies 
identified in the notice and would conduct inspections at all plants to 
evaluate the implementation of the licensees' commitments to develop and 
implement upgraded EOPs. This Information Notice reports the results of 
those efforts to date. 


8704160062 
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                                                     IN 86-64, Supplement 1 
                                                     April 20, 1987        
                                                     Page 2 of 3           

Description of Circumstances: 

Evaluations, using audits and inspections of emergency operating procedure 
implementation at six additional facilities have revealed that failures to 
implement upgraded emergency operating procedures in accordance with the 
facility commitments contained in their PGP appear to be widespread. 
Specifically, eight of the ten licensees evaluated to date had: (1) not 
adequately documented deviations from the NRC approved generic technical 
guidelines and, in some cases, have deviated significantly from the generic 
guideline without any evaluation; (2) not adequately implemented their own 
EOP writer's guide; (3) not adequately verified and validated their EOPs; 
(4) not adequately trained and evaluated the operating staff on their use of 
the upgraded EOPs; and (5) failed to apply operational quality assurance 
procedures or controls to the EOP upgrade process to assure licensing 
commitments have been met. 

The development of high quality EOPs is subject to the quality assurance 
requirements of 10 CFR ,50 Appendix B. Licensees are required to develop 
written procedures for carrying out safety related activities including 
combatting emergencies. The industry standard supporting this program is 
ANSI/ANS 3.2, "Administrative Controls and Quality Assurance for the 
Operational Phase of Nuclear Power Plants." 

Other evidence of continuing problems with the EOP upgrade program include 
poor performance on NRC licensing and requalification examinations and the 
slow resolution of open issues in the owners' group generic technical 
guidelines. 

As mentioned in the previous information notice, the staff has been 
evaluating the safety significance of deficiencies identified with utility 
EOP upgrade programs. Inspection and audit findings have resulted in 
enforcement actions and have required corrective actions for some plants 
prior to operation at full power. The attached list of inspection and audit 
reports is provided for your information. Failure to meet commitments set 
forth in the PGPs has resulted in deficient EOPs which has led to more 
complex operator actions that could have resulted in serious threats to 
public health and safety. The observed failures have been the result of (1) 
technically incorrect procedures, (2) unclear and poorly presented actions 
and information, and (3) a failure of operators to use EOPs due to a lack of
understanding and confidence in the procedures. 

Examples of safety significant procedural deficiencies are illustrated by 
all three events investigated by Incident Investigation Teams (IITs). A 
significant lesson from the loss of feedwater event at Davis-Besse Nuclear 
Power Plant was that feed and bleed cooling was not initiated immediately 
upon reaching plant conditions where feed and bleed cooling was called for 
by the EOPs. The EOP Upgrade Program failed to identify that the action 
points for initiating feed and bleed cooling in the EOP could not be clearly
identified by the operators using available instrumentation. In addition, 
the operators wanted to use the margin they believed available to await 
other recovery actions, i.e., restoration of feedwater. This event pointed 
out the inadequacy of the EOP Upgrade Program and raised the question of 
whether the operator would have initiated feed and bleed cooling in time to 
avoid core damage.
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                                                     IN 86-64, Supplement 1 
                                                     April 20, 1987        
                                                     Page 3 of 3           

The loss of power and water hammer event at San Onofre Unit 1 on November 
21, 1985 showed that the plant's EOPs were inadequate with regard to the 
loss of AC power and that operator training was deficient in a number of 
areas. 

The loss of the Integrated Control System (ICS) power and overcooling 
transient at Rancho Seco on December 26, 1985 revealed a serious flaw in the
procedures upgrade program in that, although the owner's group generic 
guidelines included an explicit procedure for failure of the ICS, the EOPs 
did not include this procedure. 

Discussion: 

In light of the potential for safety significant consequences of procedural 
deficiencies, the Staff is concerned about licensees continuing failure to 
meet all the commitments made in their PGPs for developing, implementing and
maintaining high quality, upgraded EOPs. Clearly, it is necessary for 
operators to have confidence in the technical accuracy of procedures and to 
understand and be able to carry out the actions required. The development of
high quality EOPs, including their validation and verification, and the 
effective training of operators in their use, are needed to ensure that 
operators can follow the EOPs during accident conditions and take proper 
mitigating action. 

In recognition of INPO's role in the accreditation of training programs and 
continuing evaluation of the effectiveness of training, the staff has 
provided information to INPO relating to training problems with upgraded 
EOPs. 

To address the safety significance of the deficiencies identified with 
utility EOP upgrade efforts, the staff is accelerating its inspection 
program and will inspect all plants for compliance with PGP commitments. The 
staff will contact Owners' groups to discuss problems with EOP upgrade 
programs that are specific to their member plants. 


                              Charles E. Rossi, Director 
                              Division of Operational Events Assessment 
                              Office of Nuclear Reactor Regulation 

Technical Contacts: M. Goodman, NRR          I. Schoenfeld, NRR
                    (301) 492-4906           (301) 492-4522

                    G. Lapinsky, NRR         S. MacKay, NRR
                    (301) 492-4886           (301) 492-8394

Attachments:
1.   List of Inspection and Audit Reports
2.   List of Recently Issued IE Information Notices