WANO REPORT

RPT ǀ 2014-7 October 2014

Analysis Report on Emergency
Preparedness
Common Issues from SOER 2013-2 Rev. 1 Responses, WANO Event
Reports and Peer Reviews

LIMITED DISTRIBUTION
This page is left blank intentionally
LIMITED DISTRIBUTION WANO RPT 2014-7

APPLICABILITY

THIS WANO REPORT APPLIES TO ALL REACTOR TYPES

LIMITED DISTRIBUTION

Confidentiality notice
Copyright 2014 by the World Association of Nuclear Operators (WANO). All rights reserved. Not for sale or commercial use. This document is protected as an
unpublished work under the copyright laws of all countries which are signatories to the Berne Convention and the Universal Copyright Convention. Unauthorised
reproduction is a violation of applicable law. Translations are permitted. This document and its contents are confidential and shall be treated in strictest confidence. In
particular, except with the prior written consent of the WANO CEO, this document shall not be transferred or delivered to any third party and its contents shall not be
disclosed to any third party or made public, unless such information comes into the public domain otherwise than in consequence of a breach of these obligations.

Liability disclaimer notice

This information was prepared in connection with work sponsored by WANO. Neither WANO, Members, nor any person acting on the behalf of them (a) makes warranty
or representation, expressed or implied, with respect to the accuracy, completeness, or usefulness of the information contained in this document, or that use of any
information, apparatus, method or process disclosed in this document may not infringe on privately owned rights, or (b) assumes any liabilities with respect to the use
of, or for damages resulting from the use of any information, apparatus, method, or process disclosed in this document.

WWW.WANO.ORG 1
LIMITED DISTRIBUTION WANO RPT 2014-7

REPORT ǀ RPT 2014-7

Revision History

Author Date Reviewer Approval

Riccardo Chiarelli 15 September David Crabtree Jo Byttebier

2014

Reason for Changes:

This analysis is based on preparatory work conducted by Shanjun Wang, Arshad Mahmood, Lajos Hadnagy,
JeongMin Park.

WWW.WANO.ORG 2
LIMITED DISTRIBUTION WANO RPT 2014-7

REPORT ǀ RPT 2014-7

Analysis Report on Emergency Preparedness

CONTENTS
Analysis Report on Emergency Preparedness 2
Purpose 2
Background 2
Analysis Methodology 2
Summary 3
Findings from the Analysis 3
Conclusions 7
Attachment 1 8
OE events in EP reported to WANO 8
Attachment 2 9
Analysis of responses to SOER 2013-2 Rev 1 9
Attachment 3 10
Peer Review AFI Details 10

WWW.WANO.ORG 1
LIMITED DISTRIBUTION WANO RPT 2014-7

REPORT ǀ RPT 2014-7

Analysis Report on Emergency Preparedness

Purpose

This analysis is based on emergency preparedness (EP) weaknesses identified in EP-related operating
experience event reports, areas for improvement (AFIs) identified during 2012 and 2013 WANO Peer
Reviews, and the responses from WANO members to the WANO SOER 2013-2 Rev 1 Post-Fukushima Daiichi
Nuclear Accident Lessons Learned (WANO RPT 2014-4, Analysis of SOER 2013-2 Rev 1 Recommendations
Response Data).

This analysis report intends to highlight common areas needing attention in the area of emergency
response and preparedness.

Background

WANO increased its focus on EP issues across all programmes following the Fukushima event. In the Peer
Review programme, EP has become a mandatory review area for all peer reviews. In the Operating
Experience programme, several SOER recommendations have been developed in the EP area, and
increased event reporting for EP-related events is expected.

This report contains an integrated analysis of the data from these varied information sources.

Analysis Methodology

Before May 2013, EP was an optional review area during WANO Peer Reviews. After May 2013, EP became
a mandatory review area for WANO. Some regional centres started to review EP during peer reviews a few
months after the accident at Fukushima Daiichi in March 2011.

Of the 84 WANO peer review reports from 2012 and 2013 that were analysed, 75 EP AFIs were identified.
Stated another way, over 89% of peer reviews conducted between 2012 and 2013 identified substantial
weaknesses in EP performance. The reports reviewed were from all four WANO regional centres. The AFIs
were grouped by functional area using the WANO Performance Objectives and Criteria (PO&Cs) (revision
2005).

Compared to the high number of EP AFIs identified during peer reviews or recognised by members during
SOER 2013-2 implementation, there are still few EP-related events reported in the WANO Operating
Experience (OE) database. There could be different reasons for this disparity, such as EP drill or
performance weaknesses not being seen as reportable events at the stations, or there could be a sense of
false satisfaction about the current level of performance, or gaps in EP performance are viewed as of no
interest to the rest of WANO members.

WANO SOER 2013-2 Rev 1, Post-Fukushima Daiichi Nuclear Accident Lessons Learned, was published in
August 2013. The SOER provided 11 recommendations and 33 sub-recommendations associated with
improving performance in EP. WANO members were asked to conduct a self-assessment regarding their
activities to address the recommendations of WANO SOER 2013-2 Rev 1 and send their analysis to WANO
in early 2014. WANO members recognise that there are gaps in the implementation of several EP-related
important recommendations of this WANO SOER 2013-2. These are considered by the stations to be
classified as “Further Analysis Required” or “Awaiting Implementation”. WANO RPT 2014-4, Analysis of
SOER 2013-2 Rev 1 Recommendations Response Data, provides the recommendation status details.

WWW.WANO.ORG 2
LIMITED DISTRIBUTION WANO RPT 2014-7

Summary

The common EP weaknesses identified from reviewing the three sources (WANO SOER 2013-2 Rev 1
responses, WANO event reports and peer review AFIs) can be broadly categorised into the following four
areas:

1. Lack of station policy and expectations for EP.

2. Concerns related to the readiness, availability and reliability of emergency facilities and equipment.
3. Specific skills required for emergency response personnel have not been developed.
4. Gaps in emergency drill programmes: drills limited and do not include multi-unit events.

The major underlying cause of the EP weaknesses is noted in item 1 above. Senior leadership and
management do not provide sufficient priority, direction and leadership for building and maintaining strong
emergency planning and response processes. This has resulted in the following:

 Emergency facilities, bunkers and backup facilities are not designed for seismic and post-accident
radiological conditions.

 Emergency response personnel not properly trained and qualified for their assigned position.

 The scope of drills and scenarios do not sufficiently address the emergency situations that can be
expected based on industry operating experience. Drills may be limited to one unit rather than
multiple units at the station. In some situations, personnel are made aware of the scenario details in
advance of the drill.

 EP benchmarking not performed to learn best practices from other stations.

 Emergency response equipment not procured in a timely manner.

 Onsite emergency portable equipment not properly stored and maintained.

Findings from the Analysis

The following sections provide a more detailed discussion of the four major gaps identified by this analysis.

1. Lack of station policy and expectations for EP.

a. From peer review AFIs:

i. Oversight and governance of the emergency facilities, equipment and resources are not
established.

ii. Several aspects of EP are not covered by expectation or are not detailed in documents.

iii. Emergency support documents regarding the emergency response organisation are missing
or out-of-date.

iv. No specific procedure or instructions are available to determine if the situation requires an
emergency organisation response.

v. Managers do not put much attention on EP. Some corrective actions from the last emergency
exercises are overdue.

vi. There are no formal requirements or records for the qualification of the response personnel.

WWW.WANO.ORG 3
LIMITED DISTRIBUTION WANO RPT 2014-7

vii. Emergency managers do not set the qualitative objectives on the emergency exercises. And
the emergency exercises are not fully evaluated.

viii. Out-of-hours emergency exercises are not routinely conducted. Out-of-hours emergency
response organisation is not officially on standby.

ix. Some emergency roles are not correctly fulfilled.

b. From EP events reported to WANO:

i. One event report (WER ATL 14-0472) indicated lack of procedural guidance for evaluating the
impact of changes to emergency plan implementation procedure which resulted in removal
of a required notification of site or general emergency to one offsite agency.

c. From SOER 2013-2 Rev 1 implementation:

i. More than 50% of stations recognise that recommendation 9 is not fully implemented:
Develop plans that address family/personal needs of responders who are unable to leave the
site. (Human Resources; related to EP.3)

2. Concerns related to the readiness, availability and reliability of emergency facilities and equipment:

a. From peer review AFIs:

i. Emergency facilities and equipment are vulnerable to severe or external events, such as
seismic, flooding, fire and radioactive release.

ii. Emergency control centres are limited in size and capacity and will not accommodate all the
necessary staff, especially in the situation of a multiple unit event.

iii. Emergency equipment readiness is given inadequate attention and is not part of routine
checks. When defects are identified, they are not fixed timely and emergency equipment is
not maintained in a ready state or routinely tested.

iv. Emergency communications and power supply systems lack reliability and redundancy in
case the normal system becomes unavailable.

v. Emergency facilities have no adequate public notification system.

b. From EP events reported to WANO:

i. One event (WER ATL 13-0271) reported weaknesses and malfunctions during the use of
emergency power for an extended period of time. The weaknesses challenged shutdown
cooling when multiple tornados severely damaged all of the station's 500kV transmission
lines.

ii. Two events reported deficiencies in equipment that could have complicated an emergency
situation (WER ATL 13-0496 and WER ATL 13-0462).

iii. One event (WER ATL 12-0501) was related to the inability to establish communication with
nuclear authorities due to equipment failure. Issues with communication systems have also
been identified in several AFIs.

WWW.WANO.ORG 4
LIMITED DISTRIBUTION WANO RPT 2014-7

iv. One event (WER ATL 12-0405) was issued due to a plant’s failure to accurately maintain
design control regarding single-failure assumptions for the emergency core cooling system.
Sufficiently bounding analyses were not performed to ensure that the calculated maximum
fuel element cladding temperature would not be exceeded in the event of a small break loss
of coolant accident (LOCA).

v. One event (WER PAR 12-012) indicated a number of issues with the offsite response by
members of the public within the emergency planning zone, including use of potassium
iodate tablets when a nuclear emergency notification was activated by mistake.

c. From SOER 2013-2 Rev 1 implementation:

i. More than 50% of stations recognise that recommendation 5h of SOER 2013-2 is not
implemented in a satisfactory manner:
Plans for relocating personnel as well as communication and coordination functions to
alternate locations should normal emergency response facilities be rendered inoperable
during a nuclear accident or external event. (Emergency/Accident Response; related to EP.2).

ii. More than 60% of stations recognise that recommendation 10 of SOER 2013-2 is not
implemented in a satisfactory manner:
Stage, maintain, test, secure and programmatically control equipment needed for event
response in a manner that minimises the chance of loss or damage from the initiating event,
supports timely deployment, ensures readiness and reduces the likelihood of human error.
(Equipment Resources; related to EP.3).

3. Specific skills required for emergency response personnel have not been developed

a. From peer review AFIs:

i. Operating crews and emergency teams have often misclassified events and
miscommunicated important emergency information.

ii. Some emergency response personnel do not get the required training before they get
appointed in the emergency on-call list, fail to stay suitably qualified, and miss initial and
refresh training.

iii. No approved documents are available, which are given the training requirements for all the
positions in the emergency duty teams.

iv. Some response personnel, including the key post holders have often missed the planned
emergency training or exercises.

v. Some emergency response personnel do not have the capability to use the emergency
equipment. And some do not know how to get the emergency equipment.

vi. Emergency drills rarely achieve a full participation and some key position response personnel
do not respond to the emergency calling or do not show up for the drills.

vii. The emergency exercise output is not captured by observers. Emergency response personnel
skill shortfalls identified during emergency exercises are not remedied in the follow-up
actions.

viii. Response personnel skills are not evaluated during the exercises.

WWW.WANO.ORG 5
LIMITED DISTRIBUTION WANO RPT 2014-7

ix. Emergency response directors do not thoroughly examine all aspects of the situation or do
not challenge the hypotheses and conclusions before making a decision.

x. The reports after the emergency exercises are not developed in a timely manner.

b. From EP events reported to WANO:

i. One event report (WER PAR 13-0239) indicated that the duty operations shift was non-
compliant with the station emergency plan manning level. There was a shortfall of two fire
team members for the duration of the shift.

ii. One event report (WER PAR 14-0160) identified that there were gaps in the emergency
team’s knowledge and skills. Team members were not fully conversant with their roles and
responsibilities during an exercise.

iii. One event report (WER PAR 14-0257) indicated a shortfall in the incident response team
manning for several days.

c. From SOER 2013-2 Rev 1 implementation:

i. 50% of stations recognise that recommendation 5c of SOER 2013-2 is not implemented in a

satisfactory manner:
Ensure personnel can install and operate the portable equipment within the time frames
necessary to avoid core damage during extreme environmental and other post-event
conditions. (Emergency/Accident Response; related to EP.5)

ii. Nearly 60% of stations recognise that they have not fully implemented recommendation 6 of
SOER 2013-2:
Prepare personnel responsible for performing emergency response duties with the required
knowledge, skills and proficiency to execute their role. A combination of training and realistic
drills, as well as procedure guidance and human factoring, should be used to prepare the staff
for emergency response duties. (Knowledge, Skills and Proficiency; related to EP.8)

4. Gaps in emergency drill programmes: drills limited and do not include multi-unit events.

a. From peer review AFIs:

i. Drills and exercises do not challenge the existing arrangements and are not preparing people
to deal with a real event.

ii. The emergency scenarios which are performed by the response teams are used in a
repetitive pattern.

iii. Emergency exercises are limited in scope. The scenarios have limited or no frequency of
beyond-design accidents or multi-unit events.

iv. Emergency exercises do not reflect all potential emergency conditions. Unannounced drills
are not conducted periodically. Most of the drills are conducted on a previously fixed date
and time. Even some response personnel are notified in advance.

b. From EP events reported to WANO:

i. One event showed several shortfalls in training, drills and procedure revisions. (WER ATL 12-
0854)

WWW.WANO.ORG 6
LIMITED DISTRIBUTION WANO RPT 2014-7

c. From SOER 2013-2 Rev 1 implementation:

i. About 45% of stations recognise that recommendation 5d is not implemented in a

satisfactory manner:
Develop and validate strategies for establishing core cooling and critical monitoring functions
if DC power is lost during a prolonged loss of all AC power. These strategies should serve to
prevent core damage, if possible, and to mitigate the extent of damage and reduce the
potential for large offsite release of radioactive materials. (Emergency/Accident Response;
related to EP.2)

ii. 50% of stations have not implemented recommendation 5e in a satisfactory manner:

Develop and validate procedures for venting containment, assuming normal AC and DC
power supplies and air systems are not functional. (Emergency/Accident Response; related to
EP.2)

iii. 48% of the stations recognise that recommendation 8 is not fully implemented:
Establish staffing plans for emergency response roles if an accident involves more than one
unit at a multi-unit site. (Human Resources; related to EP.3)

Conclusions

It is apparent that there are still substantive weaknesses in the fundamentals of EP programmes. Existence
of these weaknesses in EP programme fundamentals is somewhat unexpected in the post-Fukushima
environment.

WANO members should heighten their awareness of EP programme fundamental strength at their stations.
The information contained in this analysis combined with the guidance for performing EP self-assessments
provided on the WANO member website can be used together to ascertain areas where performance
should be improved.

WANO intends to communicate the results of this analysis to industry CEOs through communication from
the WANO CEO. In addition, WANO will continue to evolve its industry supporting tools (training,
workshops, technical support missions, etc.) to assist members in improving performance in the EP area.
Thus it is expected that programme managers in WANO regional centres cooperate in finding the best way
to support their members to improve in the EP area.

WWW.WANO.ORG 7
LIMITED DISTRIBUTION WANO RPT 2014-7

REPORT ǀ RPT 2014-7

Attachment 1

OE events in EP reported to WANO

In 2012-2014 there were 11 event reports submitted by WANO members in the area of EP. This number
looks low when compared with the number of issues identified during WANO peer reviews.

Report Number Title

WER PAR 13-0239 Non-Compliant with Station Emergency Scheme

WER ATL 13-0496 Environmental Qualification Deficiencies Found During Inspection of

Environmentally Qualified Components

WER ATL 13-0462 Damaged Capacitors in Main Control Room Post Accident Gamma Gross System
Panel 2-VB-105B

WER ATL 13-0271 Extended Emergency Power Operations

WER ATL 12-0854 Declining Emergency Response Organisation (ERO) Performance.

WER ATL 12-0501 Inability to Establish Communications with Required Nuclear Accident
Reporting System (NARS) Agencies Due to Communications Pathway Failure

WER ATL 12-0405 Inappropriate LOCA Modelling of Core Spray for Limiting LOCA Event With
Manual Actuation of Automatic Depressurisation System

MER PAR 12-012 Incorrect Offsite Emergency Notification – Review of Effectiveness of the
Offsite Arrangements.

WER PAR 14-0160 Areas for Improvement Identified During Emergency Exercise.

WER ATL 14-0472 Emergency Plan Noncompliance – Lack of Implementing Guidance for
Emergency Plan Required Actions.

WER PAR 14-0257 Incident Response Team Shortfalls Over the Christmas Holiday Period.

WWW.WANO.ORG 8
LIMITED DISTRIBUTION WANO RPT 2014-7

REPORT ǀ RPT 2014-7

Attachment 2

Analysis of responses to SOER 2013-2 Rev 1

WANO SOER 2013-2 Rev 1 is based on the Fukushima Daiichi nuclear accident. It was published in August
2013. There are 11 recommendations and 33 sub-recommendations in SOER 2013-2 Rev 1. The member
plants were requested to report their implementation status to WANO before 15 January 2014. WANO
collected and analysed the assessments provided by members (RPT 2014-4, Analysis of Recommendation
Response Data). The following chart shows the general picture of the recommendations’ status, self-
evaluated by members.

Self Evaluation Result Status - % of Stations

100%
90%
80%
% of implementation

70%
60%
50% FAR
40% AI
30% SAT
20%
10%
0%
11c
11a
11b
5a

5i
6
7
8
9
1a
1c
2a
2c
2e
2f
2g
3a
4a
4c

5c
5e
5f
5g

10
1b
1d
2b
2d

3b
4b

5b
5d

5h

Recommendation

From the chart, the recommendations for which the status is less satisfactory includes four
recommendations in the area of emergency/accident response (Recommendation 5c, 5d, 5e, 5h), one
recommendation in the area of knowledge, skills and proficiency (Recommendation 6), two
recommendations in the area of human resources (Recommendation 8 and 9) and one recommendation in
the area of equipment resources (Recommendation 10).

WWW.WANO.ORG 9
LIMITED DISTRIBUTION WANO RPT 2014-7

REPORT ǀ RPT 2014-7

Attachment 3

Peer Review AFI Details

In 2012 and 2013, 84 peer reviews identified 75 AFIs in the EP area.

Of the 84 peer reviews, 27 were performed by the WANO Atlanta Centre (WANO AC) where 7 AFIs related
to EP were identified. The relatively low number of AFIs in WANO AC is justified by the fact that AC relies on
INPO dedicated teams to review EP, typically separate from peer reviews, as focused area reviews. Results
from these visits were analysed and included in this report.

In the other regional centres, 68 AFIs related to EP were identified in 57 peer review reports.

Regional Centre Atlanta Moscow Paris Tokyo Total

Number of Peer
Reviews in 2012 27 13 30 14 84
and in 2013

Number of AFIs
related to EP in 7 14 45 9 75
2012 and 2013

Most of the AFIs (around 44%) were in the EP.3 category which is related to emergency facilities,
equipment and resources adequately supporting emergency operations.

Number of AFIs in each EP Performance Objective

35
30
25
20
15
10
5
0
EP.1 EP.2
EP.3 EP.4 EP.5 EP.6 EP.7 EP.8

number of EP AFIs in 2012 Peer Reviews number of EP AFIs in 2013 Peer Reviews

WWW.WANO.ORG 10
LIMITED DISTRIBUTION WANO RPT 2014-7

The most common problems identified in EP.3 (the emergency facilities, equipment and resources) were in
the following two areas:

 Several peer reviews identified areas where emergency facilities did not have protection from the full
spectrum of potential hazards for the station (seismic, flooding, etc.).

 Mobile/temporary equipment identified as necessary to mitigate the consequences of accidents are

not stored in locations protected from environmental conditions or are not regularly tested and
maintained in a state of readiness.

Other interesting insights have become apparent through initial analysis of the issues:

 The scope of emergency drills is not robust (same drill, multi-unit events not addressed, drills with
known scenarios, etc.).

 Station leadership has not provided sufficient expectations and priority to the EP function, although
activity in the area has increased.

The analysis also indicates that these issues are being identified in the station responses to SOER 2013-2
Rev 1 recommendation 5, 6, and 10 which address various aspects of accident and emergency response
(reference WANO RPT 2014-1, Analysis of SOER 2013-2 Rev 1 Recommendation Response Data).

Similar conclusions are found during pre-startup review and restart reviews.

The following table shows the relationship between the previous and the current PO&C. The 2013 version
of the PO&C contains three performance objectives while the previous version had eight.

WWW.WANO.ORG 11
LIMITED DISTRIBUTION WANO RPT 2014-7

OBJECTIVES PO&C PO&C OBJECTIVES

(REV. 3) (NEW REV.)

Emergency preparedness managers, by EP. 1 EP. 1 Leaders align the organisation

leadership, commitment and example, to prepare for and respond to
establish high standards of performance emergencies, mitigate plant
and align the emergency preparedness damage and protect the health
organisation to implement and control and safety of onsite personnel
emergency preparedness activities and the public.
effectively.

The emergency plan and its supporting EP. 2 EP. 2 Personnel, plans, procedures,
documents provide for effective facilities and equipment are
emergency preparedness and response to tested and maintained ready to
emergency situations. respond to emergencies, from
minor events to severe
Emergency facilities, equipment and EP. 3 accidents.
resources adequately support emergency
response operations.

Emergency drills effectively test the EP. 7

readiness of the emergency response
organisation to minimise reactor core
damage and personnel radiation
exposure and provide effective feedback
for improving emergency response.

Emergency response personnel EP. 8

knowledge, training and qualification, and
performance, support effective
implementation of emergency response
actions.

Emergency assessment and notification EP. 4 EP. 3 Emergency response actions

practices and procedures enable the protect the health and safety of
emergency organisation to correctly the public and station
classify emergencies, assess the personnel, mitigate plant
consequences, notify emergency damage and support response
response personnel and recommend actions by offsite authorities
appropriate protective actions. and emergency organisations.

Emergency response actions protect the EP. 5

reactor core and vital equipment and
minimise personnel radiation exposure
and offsite radiological releases.

The emergency public information EP. 6

programme and practices ensure timely
dissemination of accurate, reliable and
understandable information.

WWW.WANO.ORG 12
This page is left blank intentionally
 ATLANTA
LONDON & HONG KONG
MOSCOW
PARIS
TOKYO
WORLD ASSOCIATION OF NUCLEAR OPERATORS

www.wano.org & www.wano.info