ML093620814

IR 05000346-09-503(DRS), on 08/04/2009 - 11/23/2009; Davis-Besse Nuclear Power Station; Event Follow-up Inspection

ML093620814
Person / Time
Site:	Davis Besse
Issue date:	12/28/2009
From:	Boland A Division of Reactor Safety III
To:	Allen B FirstEnergy Nuclear Operating Co
References
EA-09-283 IR-09-503
Download: ML093620814 (23)

See also: IR 05000346/2009503

Text

UNITED STATES

NUCLEAR REGULATORY COMMISSION

REGION III

2443 WARRENVILLE ROAD, SUITE 210

LISLE, IL 60532-4352

December 28, 2009

EA-09-283

Mr. Barry Allen

Site Vice President

FirstEnergy Nuclear Operating Company

Davis-Besse Nuclear Power Station

5501 North State Route 2, Mail Stop A-DB-3080

Oak Harbor, OH 43449-9760

SUBJECT:

DAVIS-BESSE NUCLEAR POWER STATION

NRC INSPECTION REPORT 05000346/2009503(DRS)

PRELIMINARY WHITE FINDING

Dear Mr. Allen:

On November 23, 2009, the U. S. Nuclear Regulatory Commission (NRC) completed an

inspection conducted onsite August 4 through 6, 2009, of an event that occurred at your

Davis-Besse Nuclear Power Station on June 25, 2009. The purpose of the inspection was to

review the events, circumstances, and licensee actions associated with an explosion in the

switchyard and subsequent Alert declaration. The enclosed report documents the inspection

findings which were discussed on November 23, 2009, with you and other members of your

staff.

The inspection examined activities conducted under your license as they relate to safety and

compliance with the Commissions rules and regulations and with the conditions of your license.

The inspectors reviewed selected procedures, records, audio tapes, and interviewed personnel.

The enclosed report presents the results of the inspection including a finding that preliminarily

has been determined to be White, a finding with low to moderate increased safety significance

that may require additional NRC inspections. As described in Section 4OA3 of this report, the

finding involves the failure to implement the emergency classification and action level scheme

during an actual event for an explosion in the switchyard. The operators failed to verify, assess,

and classify the situation in conjunction with the Davis-Besse Emergency Plan Table of

Emergency Action Level Conditions. Specifically, immediately following an electrical fault and

catastrophic failure of a voltage transformer in the switchyard resulting in an explosion, fires,

and damage to several switchyard components which affected plant operations, the operators

failed to recognize the hazard to the stations operations met the emergency action level

conditions for declaring an Alert. After the finding was identified, your staff implemented

corrective actions to ensure the finding did not present an immediate safety concern. The

finding was assessed based on the best available information using the Emergency

Preparedness Significance Determination Process (SDP).

B. Allen

-2-

The finding is also an apparent violation of NRC requirements and is being considered for

escalated enforcement action in accordance with the Enforcement Policy, which can be found

on the NRCs website at http://www.nrc.gov/about-nrc/regulatory/enforcement/enforce-pol.html.

In accordance with NRC Inspection Manual Chapter (IMC) 0609, Significance Determination

Process, we intend to complete our evaluation using the best available information and issue

our final determination of safety significance within 90 days of the date of this letter. The

significance determination process encourages an open dialogue between the NRC staff and

the licensee; however, the dialogue should not impact the timeliness of the staffs final

determination.

Before we make a final decision on this matter, we are providing you with an opportunity:

(1) to attend a Regulatory Conference where you can present to the NRC your perspective on

the facts and assumptions the NRC used to arrive at the finding and assess its significance, or

(2) submit your position on the finding to the NRC in writing. If you request a Regulatory

Conference, it should be held within 30 days of the receipt of this letter and we encourage you

to submit supporting documentation at least one week prior to the conference in an effort to

make the conference more efficient and effective. If a Regulatory Conference is held, it will be

open for public observation. If you decide to submit only a written response, such submittal

should be sent to the NRC within 30 days of your receipt of this letter. If you decline to request

a Regulatory Conference or submit a written response, you relinquish your right to appeal the

final SDP determination, in that by not doing either, you fail to meet the appeal requirements

stated in the Prerequisite and Limitation sections of Attachment 2 of IMC 0609.

Please contact Mr. Hironori Peterson at (630) 829-9707 within ten days from the issue date of

this letter to notify the NRC of your intentions. If we have not heard from you within ten days,

we will continue with our significance determination and enforcement decision. The final

resolution of this matter will be conveyed in separate correspondence.

Because the NRC has not made a final determination in this matter, no Notice of Violation is

being issued for this inspection finding at this time. In addition, please be advised that the

characterization of the apparent violation described in the enclosed inspection report may

change as a result of further NRC review.

Based on the results of this inspection, two additional findings of very low safety significance

were also identified, one NRC identified and one licensee identified. The findings involved

violations of NRC requirements; however, because of the very low safety significance and

because the issues were entered into your corrective action program, the NRC is treating the

issues as Non-Cited Violations (NCVs) in accordance with Section VI.A.1 of the NRC

Enforcement Policy.

If you contest the subject or severity of the NCVs, you should provide a response within 30 days

of the date of this inspection report, with the basis for your denial, to the U. S. Nuclear

Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001, with a

B. Allen

-3-

copy to the Regional Administrator, U. S. Nuclear Regulatory Commission - Region III, 2443

Warrenville Road, Suite 210, Lisle, IL 60532-4352; the Director, Office of Enforcement, U. S.

Nuclear Regulatory Commission, Washington, DC 20555-0001; and the Resident Inspector

Office at the Davis-Besse Nuclear Power Station. In addition, if you disagree with the

characterization of any finding in this report, you should provide a response within 30 days of

the date of this inspection report, with the basis for your disagreement, to the Regional

Administrator, Region III, and the NRC Resident Inspector at the Davis-Besse Nuclear Power

Station. The information that you provide will be considered in accordance with Inspection

Manual Chapter 0305, Operating Reactor Assessment Program.

In accordance with 10 CFR 2.390 of the NRCs Rules of Practice, a copy of this

letter, its enclosures and your response (if any) will be made available electronically for public

inspection in the NRC Public Document Room or from the Publicly Available Records (PARS)

component of NRCs document system (ADAMS), accessible from the NRC Web site at

http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Anne T. Boland, Director

Division of Reactor Safety

Docket No. 50-346

License No. NPF-3

Enclosures:

1. Inspection Report 05000346/2009-503

w/Attachment: Supplemental Information

2. Sequence of Events

cc w/encls:

Distribution via ListServ

U. S. NUCLEAR REGULATORY COMMISSION

REGION III

Docket No:

50-346

License No:

NPF-3

Report No:

05000346/2009-503

Licensee:

FirstEnergy Nuclear Operating Company (FENOC)

Facility:

Davis-Besse Nuclear Power Station

Location:

Oak Harbor, OH

Dates:

August 4, 2009 through November 23, 2009

Inspector:

Regina Russell, Emergency Preparedness Inspector

Approved by:

Hironori Peterson, Chief

Operations Branch

Division of Reactor Safety

Enclosure 1

TABLE OF CONTENTS

ENCLOSURE 1

SUMMARY OF FINDINGS1

REPORT DETAILS 3

4OA3 Follow-Up Of Events...3

.1

Explosion of the J Bus Transformer..3

a.

Inspection Scope..3

b.

Event Description..3

c.

Findings..4

Emergency Classification .4

Notification of State and Local Agencies7

4OA6 Management Meetings...9

4OA7 Licensee-Identified Violation..9

ATTACHMENT - SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT1

LIST OF ITEMS OPENED, CLOSED AND DISCUSSED1

LIST OF DOCUMENTS REVIEWED...2

LIST OF ACRONYMS USED4

ENCLOSURE 2

SEQUENCE OF EVENTS.1

i

SUMMARY OF FINDINGS

IR 05000346/2009-503(DRS); 08/04/2009 - 11/23/2009; Davis-Besse Nuclear Power Station;

Event Follow-up Inspection

The report covers an event follow-up inspection by a regional emergency preparedness

inspector. The inspection identified one preliminary White finding with an associated Apparent

Violation (AV), one Green finding with an associated Non-Cited Violation (NCV), and one

Severity Level IV finding with an associated NCV of NRC regulations. The significance of most

findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter

(IMC) 0609, Significance Determination Process (SDP), and the cross-cutting aspect was

determined using IMC 0305, Operating Reactor Assessment Program. Findings for which the

SDP does not apply may be Green or be assigned a severity level after NRC management

review. The NRCs program for overseeing the safe operation of commercial nuclear power

reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4, dated

December 2006.

Cornerstone: Emergency Preparedness

Preliminary White. A licensee identified finding and associated Apparent Violation (AV)

of 10 CFR 50.54(q) and 10 CFR 50.47(b)(4) was identified for the failure to implement

the emergency classification and action level scheme during an actual event to declare

an Alert after an explosion in the switchyard. The operators failed to verify, assess, and

classify the situation in conjunction with the Davis-Besse Emergency Plan Table of

Emergency Action Level Conditions. Specifically, immediately following an electrical

fault and catastrophic failure of a voltage transformer in the switchyard resulting in an

explosion, fires, and damage to several switchyard components which affected plant

operations, the operators failed to recognize the hazard to the stations operations met

the emergency action level conditions for declaring an Alert. The station entered a

Limiting Condition for Operation per Technical Specifications.

The finding was screened to be more than minor because the failure to declare an Alert

adversely affected the Reactor Safety - Emergency Preparedness Cornerstone objective

to ensure the licensee is capable of implementing adequate measures to protect the

health and safety of the public during a radiological emergency. The performance

deficiency has the attribute of Emergency Response Organization Performance

associated with Actual Event Response. The performance deficiency involving the

failure to properly utilize the emergency classification and action level scheme during an

actual Alert meets the criteria of the Emergency Preparedness SDP for a failure to

implement a risk significant planning standard of event classification. The failure to

classify was a result of the licensees errors in recognition, was not due to competing

safety-related activities, and denied offsite authorities the opportunity to make decisions

regarding protecting public health and safety. The finding was screened to be a failure

to implement the risk significant planning standard associated with classification at the

Alert level and was screened to be preliminarily White. Additionally, the cause of the

deficiency had a cross-cutting component in the area of Human Performance.

Specifically, the licensee failed to make safety-significant decisions using a systematic

process and failed to obtain adequate reviews on the decisions (H.1(a)). (Section 4OA3)

Enclosure 1

1

Enclosure 1

2

Green. The inspector identified a finding and an associated NCV of 10 CFR 50.54(q)

and 10 CFR 50.47 (b)(5) for the licensees failure to maintain adequate emergency

procedures to comply with emergency planning requirements to ensure timely

notifications to State and local governmental agencies. Although the licensees

emergency classification procedure implied that State and local notifications should be

made promptly, the procedure did not prescribe the notification time frame in which a

missed classification should be made; as a result, the required notifications were not

completed for over four hours.

The finding was screened to be more than minor because the deficiency adversely

affected the Reactor Safety - Emergency Preparedness Cornerstone objective to ensure

the licensee is capable of implementing adequate measures to protect the health and

safety of the public during a radiologic emergency. The deficiency has the attribute of

Procedure Quality associated with procedure use in an actual event. The Failure to

Comply branch of the Emergency Preparedness SDP flowchart was used because the

program element for offsite notification was not adequate as designed for all types of

events, such as in the case of an after-the-fact or missed event declaration. Because

the emergency conditions no longer existed at the time of the event classification and

notification recognition, the compliance with emergency plan requirements for notification

was evaluated as non-risk significant for the switchyard event. The performance

deficiency was evaluated to be a planning standard degraded function and to be Green.

State and local offsite governmental officials were not able to assess conditions at the

time of the late event declaration and make informed decisions concerning the offsite

response. Additionally, the finding had a cross cutting component in the Human

Performance area of Resources. Specifically, the licensees procedures for notification

to offsite agencies were not complete (H.2(c)). (Section 4OA3)

Licensee-Identified Violation

A violation of very low safety significance that was identified by the licensee has been reviewed

by inspectors. Corrective actions planned or taken by the licensee have been entered into the

licensees corrective action program. This violation and corrective action tracking number is

listed in Section 4OA7 of this report.

REPORT DETAILS

4.

OTHER ACTIVITIES

4OA3 Follow-Up of Events (71153)

.1

Explosion of the J Bus Transformer

a.

Inspection Scope

The inspector reviewed the circumstances including the sequence of events and

licensee actions associated with the Alert declaration on June 25, 2009, following the

switchyard explosion of the J bus transformer. The inspector interviewed fourteen

personnel and reviewed selected procedures, records, audio tapes, and written

statements. The inspection was conducted onsite August 4 through 6, 2009, and

continued with in-office reviews until November 23, 2009. The purpose of the inspection

was to evaluate the licensees event response actions for compliance with applicable

regulatory and Davis-Besse Emergency Plan requirements. A detailed event timeline

has been included in the Enclosure 2. Documents reviewed in this inspection are listed

in the Attachment - Supplemental Information.

This event follow-up review constituted 1 sample as defined in IP 71153-05.

b.

Event Description

On June 25, 2009, at 12:49 a.m., the control room operators received annunciator

alarms in the control room indicating the de-energization of the J bus in the switchyard.

The loss of the J bus was caused by an electrical fault and catastrophic failure of the

Coupling Capacitor Voltage Transformer (CCVT) in the Coupling Capacitor Potential

Device (CCPD) used for voltage monitoring on the B phase of the bus. Two air circuit

breakers opened and the 345 kV breaker tripped resulting in loss of the J bus and

unavailability of one of two start-up transformers used to tie in offsite power. The station

entered Technical Specifications (TS) for a single point vulnerable configuration for

offsite alternating current (AC) power and a Limiting Condition for Operation (LCO) with

a 72-hour action statement.

At the onset of the event, reports of an explosion in the switchyard were immediately

called into the Secondary Alarm Station (SAS) by various security officers. The roving

officers and those at the posts reported the explosion, a white flash, a loud noise,

flames, and building vibrations. The SAS operator then called the control room and

reported fires throughout the switchyard, debris spread throughout the area, and a

breaker on fire. Security called for offsite fire and emergency medical services per the

control rooms request. Ottawa County responded with police, fire, and emergency

medical services.

The control room dispatched operations personnel to investigate the occurrence in the

switchyard and provide an assessment of magnitude of the fire, the need for offsite

assistance, and the extent of component damage. The control room also dispatched fire

brigade personnel to the switchyard. The fire brigade extinguished the flames using

hand held fire extinguishers and allowing other smaller fires to extinguish themselves.

The licensee did not use the offsite fire assistance and released the offsite responders.

Enclosure 1

3

The control room alerted the assigned duty team of the events in the switchyard and the

need for their response to the site. The outage control center was manned in order to

provide support and assistance to the transmission and distribution company that

responded for repair and restoration of the bus.

After receiving reports of the fire and considering the request which had been made for

offsite fire assistance, the Shift Manager referred to the emergency plan and

classification scheme and noted the criteria for an Unusual Event classification under the

Hazards to Station Operations category of Fire would be met if the offsite fire

company was used in extinguishing the fires. When the offsite assistance was not used,

the Shift Manager again noted that no emergency criteria were met for the emergency

plan. The Shift Technical Advisor performed a peer review and arrived at the same

conclusions as the Shift Manager for no need of event classification. The conditions for

an Alert were met under Onsite explosion affecting plant operations because: (1) the

control room was informed by station personnel who made a visual sighting of the

explosion; and (2) instrumentation readings in the control room indicating equipment

problems which required entry into a 72-hour TS LCO.

When the oncoming Shift Manager reviewed the events with the assistance of the

Emergency Preparedness Manager, the oncoming Shift Manager realized the entry

criteria for a classification at the Alert level were met.

The Shift Manager notified the NRC Headquarters Operations Officer of a transitory Alert

at 11:44 hours on June 25, 2009, pursuant to 10 CFR 50.72 (a)(1)(i) and based on

Emergency Action Level 7.D.2, Onsite explosion affecting plant operations. The

Emergency Preparedness Manager along with plant management notified Ottawa

County, Lucas County, and the State of Ohio by a phone conference call.

c.

Findings

The inspector identified two findings.

Emergency Classification

Introduction: A licensee-identified preliminarily White finding with low to moderate

safety significance and associated Apparent Violation (AV) of 10 CFR 50.54(q) and

10 CFR 50.47(b)(4) was identified for the failure to implement the emergency

classification and action level scheme during an actual event for an explosion in the

switchyard. The operators failed to verify, assess, and classify the situation and

recognize the event met the emergency action level conditions for declaring an Alert.

Description: On June 25, 2009, during an actual explosion event, the Shift Manager

failed to verify indications of the off-normal event and reported sightings and failed to

perform an extensive assessment as necessary to determine the applicable emergency

classification level. The Shift Manager failed to recognize the fire and debris throughout

the switchyard and areas outside the switchyard were a result of a transformer

explosion; therefore, he failed to consider the emergency actions levels for Explosion

under the Hazards to Station Operations category. The conditions for the Alert were

met under Onsite explosion affecting plant operations because: (1) the control room

was informed by station personnel who made a visual sighting of the explosion; and

(2) instrumentation readings in the control room indicating equipment problems.

Enclosure 1

4

An electrical fault and catastrophic failure of the transformer for voltage monitoring on

the B phase of the J bus resulted in an explosion and fires. The event resulted in two

breakers opening, damage to several switchyard components, one of two switchyard

buses used to tie in offsite power becoming de-energized, and the required entry into a

72-hour TS LCO.

The Shift Manager and Shift Technical Advisor considered the emergency classification

related to the switchyard fires but failed to recognize the explosion. They determined the

conditions requiring emergency classification for fire were not met because offsite fire

assistance was not used. The Shift Manager failed to verify the indications, assess the

overall impact to the facility, and evaluate other entry criteria in the Hazards to Station

Operations category of the emergency classification scheme. The Shift Technical

Advisor performed a peer review and arrived at the same conclusions as the Shift

Manager that no event classification was warranted. Essentially, the Shift Technical

Advisor performed a peer check on the use of the classification table focusing on a Fire

hazard and did not perform an independent assessment. He did not re-evaluate the

initiating conditions and information received from the field to make an emergency

classification evaluation.

The control room crew had an opportunity to realize an explosion had occurred at 00:50

hours when the SAS operator informed the control room of the explosion and fires in the

switchyard and subsequently requested offsite fire assistance. The determination was

based on the site protection incident report, emergency phone call report which indicated

the Shift Manager was notified, and interviews conducted by the inspector, Based on

interviews with the inspector, the SAS operator said he told the control room an

explosion had occurred, as well as, the Shift Security Supervisor reported he told the

Shift Manager. The Shift Security Supervisor also reported to the Duty Team Director,

who represented senior management for emergency response, an explosion had

occurred (recorded phone call). The Duty Team Director had subsequent calls to the

control room.

The operating crew had numerous opportunities to gain and assess information to

properly classify the explosion. On the initial call and subsequent calls to the control

room from Security, the reactor operator in the control room on the phone to Security

reported he was not concerned with what had caused the wide spread fires but was

focused on what to do to put out the fires and actions to ensure plant stability. When

Operations personnel and the Fire Captain, a Senior Reactor Operator (SRO), were sent

to the switchyard and reported back their assessment at 01:47 hours, the control room

was provided enough information to conclude an explosion had occurred. Based on

interviews with the inspector, the Fire Captain stated he knew a transformer had an

electrical fault that catastrophically failed, caused damage to many components, and

spread debris and fire in a large area, but in his mind, he did not consider this an

explosion. He was unaware of the definition of explosion in the licensees procedure.

The licensees procedure for explosions, RA-EP-02840, defines Explosion: A rapid,

violent, unconfined combustion, or catastrophic failure of pressurized/energized

equipment that imparts sufficient force to potentially damage permanent structures,

systems, or components.

Analysis: The inspector concluded the failure to use the emergency action level scheme

to classify an Alert when conditions warranted due to an explosion during an actual

event was a performance deficiency. Even though indications were available to the

Enclosure 1

5

Enclosure 1

6

control room at 00:50 hours, the event was not recognized as meeting the Alert criteria

until 07:50 hours. The performance deficiency was screened using the Emergency

Preparedness SDP. The performance deficiency was screened to be more than minor

because the performance deficiency adversely affected the Reactor Safety - Emergency

Preparedness Cornerstone objective to ensure the licensee is capable of implementing

adequate measures to protect the health and safety of the public during a radiologic

emergency. The performance deficiency has the attribute of Emergency Response

Organization Performance associated with Actual Event Response.

The performance deficiency involving the failure to properly utilize the emergency

classification and action level scheme during an actual Alert meets the SDP criteria for a

failure to implement a risk significant planning standard of event classification. The

failure to classify was a result of the licensees errors in recognition, was not due to

competing safety-related activities, and denied offsite authorities the opportunity to make

decisions regarding protecting public health and safety, therefore, was assessed as a

failure to implement the emergency plan classification scheme. The Program Element of

the emergency classification scheme was adequate as designed and met the planning

standard function.

IMC 0609, Appendix B - The Actual Event Implementation Problem branch of the SDP

was used because failure to comply with a regulatory requirement occurred during an

actual event. Using the SDP, Appendix B, Sheet 2, Actual Event Implementation

Problem flowchart, the performance deficiency screened to be an actual event

implementation problem associated with classification at the Alert level and a failure to

implement a risk significant planning standard, therefore, was screened as a preliminary

White finding. As a result of not declaring an Alert, Davis-Besse failed to activate their

full emergency response organization to assist in mitigating the event. Additionally,

State and local offsite agencies were not able to take initial offsite measures to assess

conditions, staff their facilities, and make informed decisions for protecting public safety.

The cause of the deficiency had a cross-cutting component in the area of Human

Performance. Specifically, the licensee failed to make safety-significant decisions using

a systematic process and failed to obtain adequate reviews on the decisions (H.1(a)).

Enforcement: Title 10 CFR 50.47(q) requires, in part, a licensee authorized to possess

and operate a nuclear power reactor shall follow and maintain in effect emergency plans

which meet the standards in 10 CFR 50.47(b). Title 10 CFR 50.47(b)(4) requires, in

part, a standard emergency classification and action level scheme be used by the

licensee. Davis-Besse Nuclear Power Station Emergency Plan section 2.6 states, in

part, detailed actions to be taken by individuals in response to onsite emergency

conditions are described in the emergency plan implementing procedures. Davis-Besse

Nuclear Power Station Emergency Plan Implementing Procedure, RA-EP-01500,

Emergency Classification requires, in part, that when indications of abnormal

occurrences are received by the control room staff, the Shift Manager shall verify the

indications of the off-normal event or reported sighting, assess the information available

from valid indications or reports, and classify the situation. The Emergency Plan Table

of Emergency Action Level Conditions for Explosion under the Hazards to Station

Operations category requires, in part, the declaration of an Alert for an onsite explosion

affecting plant operations in all modes with the: (1) control room being informed by

station personnel who have made a visual sighting; and (2) instrumentation readings on

plant systems indicating equipment problems.

Contrary to the above, from the time period of 00:50 to 01:47 hours on June 25, 2009,

the Shift Manager failed to verify the indications of the off-normal event or reported

sighting, assess the information available from valid indications or reports of an

explosion, and classify the situation as an Alert in accordance with the Davis-Besse

Emergency Plan Table of Emergency Action Level Conditions during an actual event.

Specifically, the valid indications and reports included: (1) the control room being

informed by Security personnel of a visual sighting of an explosion in the switchyard;

(2) instrumentation readings and annunciators in the control room that indicated the loss

of the J bus; and (3) onsite field reports from the equipment operator and from the Fire

Brigade Captain of catastrophic failure of a transformer and debris. As a consequence,

Davis-Besse failed to activate their full emergency response organization to assist in

mitigating the event. Additionally, State and local offsite agencies which rely on

information provided by the facility licensee were not able to take initial offsite measures.

The finding is identified as an apparent violation of low to moderate safety significance.

(AV 05000346/ 2009503-01)

Notification of State and Local Agencies

Introduction: An NRC- identified finding of very low safety significance (Green) with an

associated NCV was identified for the licensees failure to comply with emergency

planning requirements to ensure timely notifications to State and local governmental

agencies. Following the licensees after-the-fact recognition of the Alert, the licensee

recognized notifications needed to be made to State and local response organizations;

however, the procedures failed to provide clear and consistent guidance for the

notification timeliness. As such, the notifications were not completed for more than four

hours.

Description: At 07:50 hours on June 25, 2009, approximately eight hours after the

switchyard explosion had occurred and mitigating actions were completed by the

operating crew, the licensee realized they had failed to classify and declare an Alert. By

this time, the licensee had many managers and responder personnel onsite reviewing

the events and circumstances of the explosion. At 07:50 hours, the Shift Manager noted

in the control room unit log, information for notification to the State of Ohio, Ottawa

County, and Lucas County were to be collected and the after-the-fact notifications were

to be made by the Emergency Offsite Manager who was designated for the event to be

Emergency Preparedness Manager for the site.

The Davis-Besse Emergency Plan and emergency plan implementing procedures

designate the responsible individual for offsite notification. The Emergency Plan states,

in part, the Shift Manager, acting as the Emergency Director, will implement the plan and

ensure that required notifications to the counties and State are made. However, the

Emergency Classification procedure in the section for Transitory Events states, in

part, if through an event review an emergency classification was discovered as missed,

the Shift Manager, or designee, will contact the Emergency Offsite Manager (EOM).

The EOM will perform the required notifications to the offsite agencies. The EOM as

described in the Emergency Plan was a position associated with activation of the

Emergency Response Organization. For the after-the-fact Alert declaration for the

switchyard explosion event on June 25, 2009, the Emergency Response Organization

was not activated.

Enclosure 1

7

The Emergency Plan and emergency plan implementing procedures did not provide

clear consistent guidance for required notification timeliness. In the Emergency Plan,

the specific agencies to notify are listed along with the time requirement of 15 minutes.

The emergency plan implementing procedure Emergency Notification states, in part,

the initial notification of the State and Counties is required within 15 minutes of the

declaration of an emergency. The Emergency Classification procedure has a caution

that states, in part, if a transitory event has occurred a notification to the offsite agencies

is still required. In contrast, the Emergency Classification procedure in the Transitory

Event section discusses the notification to the offsite organizations will be made by

phone or if the agency cannot be contacted, the notification will be faxed with a follow-up

phone call the following morning. The procedure implies the notification will be made

promptly following the gathering of the notification information, but does not clearly state

the time requirement. Even though the licensee defined the after-the-fact classification

as a transitory Alert, the declaration had the 15-minute notification time requirement as

noted in the Emergency Notification procedure and the Emergency Plan. The

Emergency Preparedness Manager acting as the EOM reported he did not have the

sense of timeliness for the required notification and lost track of time. The notification of

the after-the-fact Alert declaration was made at 12:30 hours to the State and local

governmental agencies through a conference call. The notification was not made using

the Initial Notification form, DBEP-010, as required by the licensees procedure.

Analysis: The inspector concluded the failure to comply with emergency planning

requirements to have adequate procedures to ensure timely notifications to State and

local governmental agencies was a performance deficiency. The deficiency did not meet

the criteria for traditional enforcement, therefore, was screened using the Emergency

Preparedness SDP. The deficiency was screened to be more than minor because the

deficiency adversely affected the Reactor Safety - Emergency Preparedness

Cornerstone objective to ensure the licensee is capable of implementing adequate

measures to protect the health and safety of the public during a radiologic emergency.

The deficiency has the attribute of Procedure Quality associated with procedure use in

an actual event. The delay to notify the offsite agencies was not a result of the

licensees errors in recognition and was not due to competing safety-related activities.

Even after the licensee recognized State and local notifications needed to be made,

offsite notifications were delayed for over four hours.

IMC 0609, Appendix B - The Failure to Comply branch of the SDP was used because

the program element for offsite notification was not adequate as designed for all types of

events, such as in the case of an after-the-fact or missed event declaration. The

licensee did not comply with a regulatory requirement to have adequate procedures to

ensure timely notifications to State and local governmental agencies for all event types.

Because the emergency conditions no longer existed at the time of the event

classification and notification recognition, the compliance with emergency plan

requirements for notification was evaluated as non-risk significant for the switchyard

event. Using the SDP, Appendix B, Sheet 1, Failure to Comply flowchart, the

performance deficiency was evaluated to be a planning standard degraded function,

therefore, was screened to be of very low safety significance (Green). State and local

offsite governmental officials were not able to assess conditions at the time of the late

event declaration and make informed decisions concerning the offsite response.

The performance deficiency involving the licensees failure to have adequate procedures

to ensure timely notifications to State and local governmental agencies for all declared

Enclosure 1

8

events had a cross cutting component in the Human Performance area of Resources.

Specifically, the licensees procedures for notification to offsite agencies were not

complete. (H.2(c))

Enforcement: Title 10 CFR 50.47(q) requires, in part, a licensee authorized to possess

and operate a nuclear power reactor shall follow and maintain in effect emergency plans

which meet the standards in 10 CFR 50.47(b). In accordance with 10CFR 50.47(b)(5),

procedures have been established for notification of State and local response

organizations. Also 10 CFR Part 50, Appendix E.D.3., requires the capability to notify

responsible State and local governmental agencies within 15 minutes after declaring an

emergency.

Contrary to the above, the licensee did not maintain adequate procedures to ensure

timely notifications to State and local governmental agencies for all declared events.

For the after-the-fact Alert declaration for the switchyard explosion event on

June 25, 2009, the notifications to State of Ohio, Ottawa County, and Lucas County

were delayed for over four hours after the Shift Manager noted the requirement.

Because the finding was of very low safety significance and has been entered into the

licensees corrective action program (CR 09-62918), the violation is being treated as a

Green NCV (NCV 05000346/ 2009503-02, Failure to Have Adequate Procedures for

Offsite Notifications), in accordance with Section VI.A.1 of the NRC's Enforcement

Policy.

4OA6 Management Meetings

.2

Exit Meeting Summary

On August 6, 2009, the inspector provided an interim debrief to the licensee staff for the

onsite interview portion of the inspection. On November 23, 2009, the inspector

presented the inspection results to the Site Vice President, Mr. B. Allen, and other

members of the licensee staff. The licensee acknowledged the issues presented. The

inspector confirmed that none of the potential report inputs which were discussed was

considered proprietary.

4OA7 Licensee-Identified Violation: A violation of very low safety significance (Severity

Level IV) was identified by the licensee and was a violation of NRC requirements which

meets the criteria of Section VI of the NRC Enforcement Policy. A violation of

10 CFR 50.72 was identified for failure to provide timely notification to the NRC. On

June 25, 2009, Davis-Besse failed to provide timely notification to the NRC of the

after-the-fact Alert classification resulting from an explosion in the switchyard. The

delayed notification was not a result of competing safety-related activities, plant

stabilization activities, or equipment failures. The delayed notification was not a result of

the licensees initial failure to classify the event. At 07:50 hours the licensee recognized

that conditions warranted the classification of an Alert and they had missed the Alert

declaration; however, the licensee did not notify the NRC of the missed Alert until

11:44 hours, a period exceeding one hour notification requirement.

The finding was evaluated using the traditional enforcement process because the

deficiency had the potential to impact the NRCs ability to perform its regulatory function.

Since the emergency condition no longer existed at the time the report was required and

the report was untimely versus not reported at all, the issue was characterized as a

Enclosure 1

9

Enclosure 1

10

violation of very low safety significance (SL IV) and as a NCV. The licensee entered the

issue into their corrective action program (CR 09-61112).

ATTACHMENT: SUPPLEMENTAL INFORMATION

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee

B. Allen, Site Vice President

R. Patrick, Operations Superintendent

G. Wolf, Regulatory Compliance Supervisor

D. Wuokko, Regulatory Compliance Supervisor

V. Kaminskas, Engineering Director

J. Vetter, Emergency Preparedness Manager

M. Parker, Security Manger

B. Boles, Site Operations Director

C. Price, Performance Improvement director

G. Halnon, Regulatory Affairs Director

T. Schneider, Public Affairs

D. Dewitz, Senior Nuclear Specialist

Nuclear Regulatory Commission

H. Peterson, Chief Operations Branch

J. Rutkowski, Senior Resident Inspector

LIST OF ITEMS OPENED, CLOSED AND DISCUSSED

Opened

05000346/ 2009503-01

AV

Failure to Use Classification Scheme for an Alert

05000346/ 2009503-02

NCV

Inadequate Procedures for State and Local Notifications

Closed, and Discussed

05000346/ 2009503-02

NCV

Inadequate Procedures for State and Local Notifications

Attachment

1

LIST OF DOCUMENTS REVIEWED

The following is a list of documents reviewed during the inspection. Inclusion on this list does

not imply that the NRC inspectors reviewed the documents in their entirety, but rather, that

selected sections of portions of the documents were evaluated as part of the overall inspection

effort. Inclusion of a document on this list does not imply NRC acceptance of the document or

any part of it, unless this is stated in the body of the inspection report.

4OA3 Follow-Up of Events

Davis-Besse Nuclear Power Station Emergency Plan; Revision 26

RA-EP-01500; Emergency Classification; Revision 10

RA-EP-02110; Emergency Notification; Revision 9

RA-EP-02840; Emergency Plan Off Normal Procedure; Explosion; Revision 3

NOP-LP-5003; Communicating Events of Potential Public Interest; Revision 1

Integrated On-Call Report; Responder Team C/Blue; dated June 25, 2009

Control Room Unit Log; June 25, 2009, through June 26, 2009

June 25, 2009 Alert Timeline; dated July 27, 2009

DB-0095-01; Reactor Plant Event Notification Worksheet; dated June 25, 2009

FENOC Site Protection Incident Reports and Statements from Security Personnel

DB-0700-0; Emergency Phone Call Report; dated June 25, 2009

CR 09-61025; Loss of J Bus, Catastrophic Failure of J Bus Phase Potential Device;

dated June 25, 2009

CR 09-61038, Davis-Besse Site Protection to Critique Opportunities for Improvement on

Response to Switchyard Event; dated June 25, 2009

CR 09-61115; Transitory Alert Emergency Classification Following Loss of J Bus; dated

June 26, 2009

CR 09-62916; Lessons Learned: Switchyard Event NRC Follow-up Inspection;

Improvements to Relate Explosions to Emergency Action Levels; dated August 6, 2009

CR 09-62918, Lessons Learned - Switchyard Event NRC Follow-up Inspection;

Observation Concerning Notification Timeliness of State and Locals; dated

August 6, 2009

CR09-62919, Lesson Learned: Switchyard Event Follow-up - NRC Inspection;

Review Security Operations Strategies and Communications; dated August 6, 2009

CR09-63249; Re-evaluate June 25 Event on NRC Performance Indicator; dated

August 14, 2009

4OA7 Licensee-Identified Violation

DB-OP-00002; Operations Section Event/Incident Notifications and Actions; Revision 19

DBRM-RC-001; Regulatory Reporting Requirements; Revision 3

Attachment

2

NRC Event Notification Report for June 26, 2009

CR 09-61112; RA-EP-01500 Procedure Requires Additional Guidance; dated

June 26, 2009

CR 09-61200; NRC Notification Time for the 6/25/09 Alert Was Exceeded; dated

June 8, 2009

CA 09-61200; Human Performance Success Clock Evaluation Results; dated

July 1, 2009

CA 09-61200; Revise RA-EP-01500 to Strengthen Wording for NRC Notification; dated

July 24, 2009

Attachment

3

LIST OF ACRONYMS USED

ADAMS

Agencywide Document Access Management System

CA

Corrective Action

CAP

Corrective Action Program

CCPD

Coupling Capacitor Potential Device

CCVT

Coupling Capacitor Voltage Transformer

CFR

Code of Federal Regulations

CR

Condition Report

DRP

Division of Reactor Projects

IMC

Inspection Manual Chapter

IR

Inspection Report

NCV

Non-Cited Violation

NEI

Nuclear Energy Institute

NRC

U. S. Nuclear Regulatory Commission

PARS

Publicly Available Records System

SDP

Significance Determination Process

UFSAR

Updated Final Safety Analysis Report

URI

Unresolved Item

Attachment

4

SEQUENCE OF EVENTS

June 24, 2009

Late on June 24, 2009, approximately two-and-a-half hours prior to midnight, a computer

point in the control room (E100) began to act erratically, first the computer point read off

scale high and later indicated a low voltage even thought the actual voltage in the J bus did

not change. The operators assumed the computer point was bad because the bus voltage

appeared unchanged.

June 25, 2009

At 00:48 hours, the control room lights flickered and a static noise was heard on the plant

address system. The Coupling Capacitor Potential Device (CCPD) catastrophically failed

causing a loss of the J bus and damage to switchyards components.

Within seconds, the Secondary Alarm Station (SAS) received reports of an explosion, a

white flash, a loud noise, flames, and building vibrations and flames in the switchyard.

At 00:49 hours, annunciator alarms were received indicating breaker openings, trips, and

the J bus (one of the two switchyard buses for offsite AC power) was de-energized. The

station entered a Limiting Condition for Operation per Technical Specifications for a single

point vulnerable configuration.

At 00:50 hours, as documented in the FENOC site protection incident report and per

interviews with the inspector, the SAS called to the Control Room and reported explosion

and flames throughout the switchyard. The Central Alarm Station (CAS) communicated with

security posts concerning an explosion.

Security requested offsite assistance from Ottawa County to dispatch Carroll Township fire

and Emergency Medical Services (EMS). The Control Room dispatched an equipment

operator to the switchyard to investigate the extent of the fire and equipment damage.

At 00:54 hours, the equipment operator reported fire, smoke, and debris spread throughout

whole end of the switchyard by the J Bus. The Shift Manager referred to the emergency

plan for Hazards (Fire) and noted conditions for an Unusual Event would be met if offsite fire

assistance (Carroll Township) is used to help extinguish the fires.

Following the initial report to the Control Room by SAS, per the interview with the inspector,

the Shift Security Supervisor indicated he communicated to the Shift Manager that the

explosion was apparently from equipment malfunction and was not from suspicious activity.

At 01:11 hours, Carroll Township Police Department was onsite.

At 01:19 hours, Carroll Township Fire Department was onsite.

At 01:20 hours, Carroll Township EMS was onsite.

The Duty Team Director responded to a page from the Shift Security Supervisor. The Duty

Team Director was the management representative on call. During the recorded telephone

conversation, the Shift Security Supervisor told the Director of the explosion in the

switchyard and the debris spread throughout the area. The explosion was apparently from

Enclosure 2

1

Enclosure 2

2

equipment malfunction and was not from suspicious activity. Carroll Township police, fire,

and EMS were onsite but not allowed into the switchyard and the fires were allowed to burn

out. Between 00:50 and 01:20 hours, the onsite Fire Captain, a Senior Reactor Operator

(SRO), arrived with the fire brigade to assess the damage and extinguish the fires.

At 01:23 hours, the Fire Captain reported all ground fires were extinguished.

At 01:24 hours, the Shift Manager noted no entry criteria met for event classification

because offsite fire assistance was not used. After his review, the Shift Manager asked the

Shift Technical Advisor to do a peer check. The Shift Technical Advisor peer check

confirmed no classification for the event due to fires.

At 01:26 hours, the CAS and SAS were advised offsite assistance was not needed.

At 01:27 hours, SAS called Ottawa County to cancel further response.

At 01:32 hours, the Carroll Township police, fire, and EMS left the site.

At 01:47 hours, the Fire Captain reported visible damage to J Bus A phase (oil leak),

C phase (damaged insulator), B phase (destroyed and debris throughout the property),

and C phase disconnect breaker (damaged insulator).

At 01:55 hours, the Shift Manager conducted a duty team phone call to provide updated

status of the plant. The Outage Control Center became manned with the Duty Plant

Manager, maintenance, and engineering to support the transmission and distribution

companys response to the switchyard explosion.

At 02:15 hours, the Shift Manager called on the phone to the Operations Manager and

discussed damage to switchyard components.

The control room continued to receive information from the field concerning the damage and

communicated with the duty team and proceeded to switch over to the remaining available

start-up transformer.

At 07:50 hours, further review of the events and the classification by the oncoming Shift

Manager in conjunction with the EP Manager, the licensee determined they met the

conditions for an emergency classification of an Alert for criteria 7.D.2 - Onsite explosion

affecting plant operations. Per the licensees procedures, the missed Alert was called a

transitory Alert. The Shift Manager noted the EP Manager would notify the State of Ohio,

Ottawa County, and Lucas County.

At 11:44 hours, the Shift Manager notified the NRC Headquarters Operations Officer

pursuant to 10 CFR 50.72 (a)(1)(i) of a transitory Alert based on Emergency Action Level

7.D.2- onsite explosion affecting plant operations.

At 12:30 hours, the EP Manager along with plant management, notified Ottawa County,

Lucas County, and the State of Ohio by a phone conference call.

B. Allen

-3-

Warrenville Road, Suite 210, Lisle, IL 60532-4352; the Director, Office of Enforcement, U.S.

Nuclear Regulatory Commission, Washington, DC 20555-0001; and the Resident Inspector

Office at the Davis-Besse Nuclear Power Station. In addition, if you disagree with the

characterization of any finding in this report, you should provide a response within 30 days of

the date of this inspection report, with the basis for your disagreement, to the Regional

Administrator, Region III, and the NRC Resident Inspector at the Davis-Besse Nuclear Power

Station. The information that you provide will be considered in accordance with Inspection

Manual Chapter 0305, Operating Reactor Assessment Program.

In accordance with 10 CFR 2.390 of the NRCs Rules of Practice, a copy of this

letter, its enclosures and your response (if any) will be made available electronically for public

inspection in the NRC Public Document Room or from the Publicly Available Records (PARS)

component of NRCs document system (ADAMS), accessible from the NRC Web site at

http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Anne T. Boland, Director

Division of Reactor Safety

Docket No. 50-346

License No. NPF-3

Enclosures:

1. Inspection Report 05000346/2009-503

w/Attachment: Supplemental Information

2. Sequence of Events

cc w/encls:

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OFFICE

RIII

RIII

RIII

RIII

NAME

RRussell:co

HPeterson

SOrth

ABoland

DATE

12/17/09

12/17/09

12/28/09

12/28/09

OFFICIAL RECORD COPY

1

1

Letter to Mr. Barry Allen from Ms. Anne Boland dated December 28, 2009

SUBJECT:

DAVIS-BESSE NUCLEAR POWER STATION

SPECIAL INSPECTION REPORT 05000346/2009-503 PRELIMINARY

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