The CRS (control room supervisor) who called in sick, sounds like he knew his crew wasn't ready for startup. He probably realized his crew would get into a bad situation...didn't want his reputation to get tarred by the screw-up.
The licensee says all the crew had been properly trained for all situations at the plant. Then they must be just shitty managers. Undoughterly the simulator training is up to the NRC regulation, but it is not sufficient to operate a plant safety.
Pursuant to the reporting requirements of 10 CFR 50.73, attached is the subject Licensee Event Report concerning the automatic reactor trip due to loss of main feedwater for Arkansas Nuclear One, Unit 1.The contributing cause for this event was determined to be ANO-1 Operations management and crew leaders did not effectively meet expectations of providing optimal crew composition, maintain command and control, and oversee control room evolutions.
The following factors were identified through the various analysis techniques used to be related to the root and contributing causes associated with this event.
• Crew Composition
The scheduled on duty CRS had called in sick prior to the watch and a relief CRS assumed the watch who was subsequently designated as the team lead for placing the MFP in service. A Shift Manager (SM) supporting activities assumed the CRS role for oversight. The SM had not been involved with the Just In Time Training (JITT) for the startup and had not served in the CRS role in approximately one year. In addition, the dayshift Shift Technical Advisor (STA) was relieved at 1600 for personal reasons and was replaced by an STA that had not attended JITT.
• Command and Control
The CRS did not challenge the basis of why the procedurally identified computer points were out of band or the ATC’s alternate monitoring method of using the OIT discharge pressure while manually operating the MFP.
The ATC extrapolated the differences between the two indications and assumed that as long as the monitored indications remained constant then discharge pressure was being controlled within the appropriate band per the earlier identified OIT indication.
The ATC did not communicate with the CRS or anyone on the crew that the computer display would be monitored to ensure that the discharge pressure remained within the acceptable band.
The Control Board Operator – Turbine (CBOT) performed a component verification versus a peer check as required by ANO Operations standards.
• Procedure use and Adherence / Procedure Compliance
Throughout the course of the shift, there were multiple examples of the ANO-1 Control Room team failing to implement administrative procedural requirements outlined in station and fleet procedure intended to minimize the potential for human error.
• Formal Operations Communications
Crew members (other than the ATC) were unaware of the failed pressure instrument which impacted the team’s ability to challenge pressure monitoring and control. The CRS did not request updates from the ATC during the evolution regarding MFP discharge pressure.
• Operator Knowledge and Training
ATC operator did not identify that the setback feature was active which led to the raising of MFP speed to “control” RCS pressure. As stated previously, several members of the crew did not attend JITT.
A performance analysis was conducted for the conceptual error on the part of the ATC regarding system operation. Based on the review in the analysis, no training weaknesses were identified. The evaluation determined that the evolution had been correctly performed in the past without identifying MFP discharge pressure as a critical parameter, the activity was not overly complex, and successful performance was within the fundamental skills and knowledge of a typical ATC.
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