ML20203B829
| ML20203B829 | |
| Person / Time | |
|---|---|
| Site: | Crystal River  |
| Issue date: | 02/05/1996 |
| From: | Curtis Rapp NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Fredrickson P, Gibson A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| Shared Package | |
| ML20203B366 | List: |
| References | |
| FOIA-97-313 NUDOCS 9712150162 | |
| Download: ML20203B829 (2) | |
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UNUED STATES NUCLEAR REGULATORY COMMISSION
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February 5,1996 MEMORANDUM FOR:
Albert F. Gibson, Director Division of Reactor Safety Paul E. Fredrickson, Chief Special Inspections Branch Division of Reactor Safety FROM:
Curtis W. Rapp, Reactor Engineer
/
Special Inspections Branch Ng/
Division of Reactor Safety
SUBJECT:
LESSONS LEARNED FROM CRYSTAL RIVER UNAUTHORIZED EVOLUT' ION Now that the issues arising from the events of September 4 and 5, 1994 at Crystal River are finally being brought to closure, I feel.that several important lessons should be considered when any such future actions are again taken.
Lesson 1:
Inspect first. then investicate It was apparent from the interviews with the operators that substantial technical and managerial issues were involved. While I was sent with 01 to resolve any technical matters, it would not have been appropriate to explore technical details during the 01 interviews.
This resulted in developing an incomplete understanding of the technical development of Curve 8.
Also, the September 4th evolution would have been discovered during an inspection.
Engineering knew of this additional evolution because of th( REDAS data they obtained to address the p.oblem report written as a result of September 5th. During routine inspection follow-up with engineering, the REDAS data would have been reviewed.
Also, operator logs would have been reviewed in greater detail.
Both of these records clearly showed the evolutions of September 4th and 5th.
Also, a complete understanding the technical issues would have.better assisted 01 in making the determination if procedures were willfully violated. This was extremely important for the September 4th event.
Lesson 2:
Refrain from makina inappropriate comparisons e
The comparison of these evolutions to Chernobyl substantially reduced the credibility of NRC inspectors to make technical evaluations.
While licensee management may have understood this comparison was made to emphasis the magnitude of this situation; the working level viewed this comparison as typical of unknowledgeable NRC personnel.
It is'already difficult to gain even a small measure of technical credibility without having to " live down" such comparisons.
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. Lesson 3: ~ Dnn't surprise the licensee :
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Evidently,.the regulatory " good practice" of open and honest l
communications was'not followed in this instance..The licensee was not
. aware that NRC was interested in these evolutions until NRC senior management: questioned the licensae at a meeting-to discuss corrective _
t actions to setpoint issues.
This particularly surprised the licensee l
. _because they had kept the senior resident informed of their response to the operators' actions.
It is evident that the licensee took stronger action than originally planned directly:due' to NRC senior managements' interest.
i Lesson 4:
Include all knowledaeable persons in the enforcement process Even though I had participated in the' interviews and reviewed the procedures involved, I was excluded from the enforcement process.
I was not, included in developing the proposed violations and was only perip.herally involved with the enforcement panel via conference call.
My involvement earlier would have highlighted the recurring technical and managerial issues and the need for a detailed inspection.
Lesson 5:
Don't sinale out an individual During the 01 interviews with licensee management, the licensee stated they scrutinized the shift supervisors' action more closely due to a NRC senior. managers' concern on another matter.
This other matter involved supposedly signing off post-maintenance tests as complete before-they i-had been conducted.
The shift supervisor knew that the components were going to be tested as part of refueling outage testing and he was following industry standard practice.
By singling out this individual, licensee management took a more aggressive position than if the issue had been dealt with generically.
Including these lessons learned will result in a more balanced and equitable approach to~similar matters that may arise in the future.
cc:
K. Landis W. McNulty J. Vorse LJ. Dockery File i
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