Accident Investigation Directive 8.9

Posted 8 Dec 1997

U.S. Nuclear Regulatoiy Commission
Volume: 8 Licensee Oversight Programs AEOD
Quick reference to Excerpts only. - Contact NRC for full document. (1993)

Accident Investigation Handbook 8.9



Excerpts only. Contact NRC for full document.

U.S. Nuclear Regulatoiy Commission

Volume: 8 Licensee Oversight Programs AEOD

Accident Investigation Directive 8.9

Part I. Executive and management responsiibilities. Not reproduced here.

Part II.

Policy

(8.9-01)

It is the policy of the U.S. Nuclear Regulatory Commission (NRC) to investigate significant operational events involving reactor or nonreactor facilities licensed by the NRC. An operational event of extraordinary safety significance that poses a significant hazard to public health and safety, or the environment, or involves high public, media, congressional, or executive branch interest, at the discretion of the Commission, may involve a response by an Accident Review Group (ARG). Once established and chartered, an ARO will function in an independent and self-directed manner, subject only to the oversight of the Commission.

Objectives

(8.9-02)

To promote public health and safety and provide for the common defense and security by preventing the recurrence of accidents at licensed facilities. (021)

To ensure that an accident is investigated in a manner that is timely, objective, systematic, credible, and technically sound; that factual information pertaining to the accident is documented; and that probable causes are ascertained. (022)

To increase the effectiveness of NRC regulatory programs and licensee safety by the prompt dissemination of the facts, conditions, circumstances, and probable causes of the accident and the identification of appropriate followup actions. (023)

To improve regulatory oversight of licensee activities by uncovering facts that could show whether the regulatory framework or regulatory process contributed directly or indirectly to the cause or the course of an accident. (024)

Definitions

(8.9-04)

Accident Investigation

(041)

A formal process conducted for the purpose of preventing accident recurrence that involves the gathering and analysis of information; the determination of findings and conclusions of fact, including the determination of probable cause(s) of the accident; and dissemination of the investigation results for review by NRC, the nuclear industry, the licensee, and the public.

Accident Review Group

(042)

A group of experts who do not and have not had previous significant involvement with licensing, inspection, enforcement, operational, or response activities at the affected facility and who perform the NRC's investigation of the accident. An individual outside the NRC usually leads the ARG. The members of the ARG are composed of NRC staff experts and experts from outside the NRC. Because the ARG reports directly to the Commission, the activities of the ARG are independent of regional and headquarters office management.

Event of Extraordinary Safety Significance

(043)

Any radiological, safeguards, or other safety-related operational event at an NRC-licensed facility that poses a significant hazard to public health and safety, or the environment, or involves high public, media, congressional, or executive branch interest. An event of extraordinary safety significance may be referred to as an accident. Such an event generally has very serious safety implications and may have profound regulatory implications.

Characteristics of an event for which an ARG response might be considered may include one or more of the following:

The event led to a general emergency at a reactor facility. (1)

The event involved an external release of radioactive material that resulted in at least partial implementation of radiologically justified protective measures for the public. (2)

The event involved severe damage to a significant fraction of the core of a power reactor, a major criticality accident, or a major fire or explosion releasing large quantities of radioactive materials within the facility. (3)

The event involved sufficiently serious circumstances, including security or safeguards concerns, or involved characteristics of great national or international interest, the investigation of which would best serve the needs and interests of the Commission. (4)

References

(8.9-97)

1. NUREG-1303, Rev. 2, "Incident Investigation Manual," September 1992.

2. NRC Management Directive 8.2, "NRC Incident Response Plan" (formerly MC 0502).

3. Office for Analysis and Evaluation of Operational Data Procedure No.12, "Incident Investigation Team Administrative Requirements," March 1992.


Accident Investigation Handbook8.9

Contents

Part I

Accident Investigation 1

General (A) 1
Responsibilities (B) 1
The Commission (1) 1
The Executive Director for Operations (EDO) (2) 1
The Director, Office for Analysis and Evaluation of Operational Data (ABOD) (3) 2
The Director, Office of Nuclear Reactor Regulation (NRR) (4) 3
The Director, Office of Nuclear Material Safety and Safeguards (NMSS) (5) 3
Regional Administrators (6) 4
The Director, Office of Administration (ADM) (7) 5
The Director, Office of Public Affairs (OPA) (8) 5
The Director, Office of Nuclear Regulatory Research (RES) (9) 6
The Office of the General Counsel (OGC) (10) 6
The Director, Office of Congressional Mfairs (OCA) (11) 6
The Director, Office of Investigations (01) (12) 6
Office of the Inspector General (OIG) (13) 7
The Director, Office of State Programs (OSP) (14) 7
The Director, Office of International Programs (OIP) (15) 7

Part II

Accident Review Groups 8
Objectives of an Accident Review (A) 8
Scope of an Accident Investigation (B) 8
Schedule (C) 9
Group Composition and Membership (D) 10
Duties (E) 11
Conduct of an Accident Investigation (F) 12
Accident Review Group Report and Individual Member
Recommendations (G) 13
Followup (H) 14

Part III

Investigation Support Staff 15


Part I not included in these excerpts.

Part II

Accident Review Groups

This part provides guidance on the investigatory response by an Accident Review Group (ARG).

Objectives of an Accident Review (A)

The objectives of an ARG are as follows:

To conduct a timely, thorough, systematic, formal, and independent investigation of the facts of an accident occurring at a facility licensed by the NRC. (1)

To collect, analyze, and document factual information and evidence sufficient to determine the conditions, circumstances, and probable causes of the accident. (2)

Scope of an Accident Investigation (B)

The investigation performed by an ARG involves fact-finding, including the determination of probable causes, for an event of extraordinary safety significance (as defined in this directive). The scope of the investigation must be sufficient to ensure that the following is accomplished: (1)

The accident is clearly understood (a)

The relevant facts and circumstances are determined and collected (b)

The probable causes and contributing causes and findings and conclusions are determined and substantiated by the evidence associated with the accident (c)

The scope of the investigation includes conditions preceding the accident, accident chronology, systems response, equipment performance, human factors, licensee management and organizational factors, precursors to the accident, emergency response, safety significance, and radiological considerations. The ARG must consider whether licensee activities preceding and during the accident were timely and adequate and whether NRC actions or inactions contributed to the cause or the course of the accident. Additionally, the ARG must determine whether any one or a combination of the following played a role in the accident: (2)

Institutional conditions such as the regulatory framework, including the NRC regulatory process, organization. management, and interactions (a)

External conditions such as the licensee's financial circumstances (b)

Industry or supplier circumstances (c)

The scope of the ARG investigation may also include an assessment of the offsite emergency response of State, lQcal, and other Federal agencies, if directed by the Commission. (3)

The scope of the ARG investigation is established in a charter mutually agreed upon and approved by the Commission and the Director, ARO. The scope of the investigation does not include a specific assessment of violations of NRC rules and requirements. (4)

Schedule (C)

The ARG should be activated as soon as practicable after the safety significance of the operational event is determined and will begin its investigation as soon as practicable after the emergency has been downgraded to the point where the facility at which the accident occurred is placed in a safe, secure, and stable condition and radiological conditions permit safe site access. If there is an NRC incident response, the ARO investigation will begin only after the NRC Director of Site Gperations, in consultation with the licensee, approves the initiation of onsite activities. The ARG should provide periodic reports outlining the status, plans, and significant safety findings. (1)

The Commission and the Director, ARG, shall agree upon the schedule for completing the investigation and submitting the ARG's final written report. As a guideline, the final report should be transmitted to the Office of the Secretary (SECY) for distribution to the Commission and the EDO about 75 days after completion of the field investigation. (2)

After distribution of the final report. SECY should normally schedule a meeting for the ARG to brief the Commission on the results of the investigation. Information contained in the report will not to be released until a copy of the final report is placed in the Public Document Room (PDR), which usually occurs during the day of the Commission briefing. If deemed necessary, SECY should forward a copy of the final report to the affected licensee before the Commission briefing and should prompdy for'ward a copy of the final report to the PDR. Following he Commission briefing, SECY will transmit a copy of the final report to the licensee and the EDO for staff review and comment before the Commission defines and assigns NRC followup actions. (3)

Group Composition and Membership (D)

The number of members and the areas of expertise required for the ARO will be determined on the basis of he type of facility involved, he characteristics of the accident, and the ARG charter. Areas of expertise will include he requisite technical, legal, and management disciplines and such other areas of specialization as may be necessary, such as financial expertise. ARG members are selected on the basis of their expertise, their potential contributions to the investigation, and their freedom from significant involvement in the licensing, inspection, and operation of he facility involved or other activities associated with issues that had a direct bearing on the cause or course of the accident. (1)

The membership of the ARG should be composed. in part. of expert staff from the NRC. Appropriate outside individuals will be requested to participate as members in the investigation. The Director, ARG, will usually be an individual from outside NRC. Other outside individuals will be selected on the basis of their unique knowledge and expertise and should also be independent from significant prior involvement in activities associated with issues that had a direct bearing on the cause or the course of the event. The ARG should consist of a larger proportion of non-NRC representation than is normally the case for an Incident Investigation Team. (2)

The background of each candidate member of the ARG will be carefully evaluated before selection to ensure impartiality and independence. Individuals possessing a high degree of ingenuity and resourcefulness should be selected to ensure that the investigation is conducted in a timely, professional, thorough, and coordinated manner. (3)

Duties (E)

The ARG carries out the NRC fact-finding investigation of the accident and is authorized and responsible for pursuing all aspects of an accident that are within its scope as defined in this directive and the ARG charter. NRC response personnel onsite shall provide support as needed to ensure the efficient and effective transition from response to investigation of the accident in a manner that will not interfere with safety at the site of the event. (1)

The following duties of the Director, ARG. are in addition to the duties defined elsewhere in this directive and handbook: (2)

Selects the members and concurs on the charter and schedule of the ARG. (a)

Directs and manages the ARG in its investigation and ensures that the objectives and schedules are met for the investigation as defined in this directive and handbook and the ARG charter. (b)

Receives general direction and supervision from the Commission. (c)

Identifies. adds, and removes equipment and areas from the quarantined list, within the constraints of ensuring plant safety, equipment testing, maintenance requirements. and determining causes for equipment anomalies. after arriving onsite. (d)

Serves as principal spokesperson for the ARG activities in interacting with the licensee, the Commission, NRC offices, the Advisory Committee on Reactor Safeguards (ACRS), the Advisory Committee on Nuclear Waste (ACNW), or the Advisory Committee on Medical Uses of Isotopes (ACMUI), the news media, and other organizations on matters involving the investigation. (e)

Provides status reports. as requested, documenting ARG activities and significant safety findings that may require timely remedial actions or issuance of information notices, bulletins. or orders. (f)

Identifies and requests that the Commission provide additional ARG resources (e.g., additional members, consultants, contractor assistance), as needed. (g)

Ensures. in cooperation with the ARO members and the technical writer/editor. preparation of the final report within the tim eframe agreed upon by the Commission. (h)

Works with the Office of Public Affairs in providing the news media with information on ARG activities. (i)

Conduct of an Accident Investigation (F)

The investigation process used by the ARG must be structured to maintain independence. objectivity, and thoroughness. The ARG may use as guidance the investigation principles and practices of incident investigation training programs that are described in NUREG- 1303, "Incident Investigation Manual," and AEOD Procedure No. 12. "Incident Investigation Team Administrative Requirements." These procedures provide guidance for the following:

Activating an investigation, including responsibilities.

coordination, communication, group composition, and

guidance (1)

Outlining an investigation, including responsibilities. communication, interactions, scope, and schedule (2)

Interviewing personnel (3)

Collecting and maintaining records, documents, data, and other information (4)

Treating quarantined equipment and areas (5)

Preparing and reviewing all data for classified or sensitive unclassified information and distributing an investigation report and related documents (6)

Defining administrative support requirements for an investigation (7)

Accident Review Group Report and Individual MemberRecommendations (G)

The ARG shall prepare a written NUREG-series report to formally document its findings and conclusions of fact. The report should provide a description of the conditions preceding the accident, accident chronology, Systems response, equipment performance. human factors, licensee management and organizational factors, precursors of the accident, emergency response, safety significance. and radiological considerations. The report should document whether and how NRC actions or inactions contributed to the cause or the course of the accident and whether and how institutional aspects played a role in the accident. The report must include appropriate findings and conclusions relating to the conditions, circumstances, and probable causes of the accident. (1)

Because the ARG is not chartered under rules related to advisory committees, it will not deliberate upon or make recommendations as a group for NRC action or inaction: however, individual ARG members may submit their individual recommendations to the Commission at the option of the member. (2)

Followup (H)

Following the Commission briefing on the ARG results and review and comment by the NRC staff and the licensee on the ARG report, the Commission shall determine the NRC followup actions that will be taken as a result of the investigation. The EDO shall assign office or regional responsibility for the generic and facility-specific followup actions identified by the Commission. Office directors shall provide a plan to resolve each of their assigned actions and periodic written status reports on the disposition of each assigned action. (1)

The memorandum assigning followup actions should address all ARG findings that are judged to require followup. The resolution of each assigned action will be documented and each generic item will be individually tracked by the EDO Work Item Tracking System (WITS). AEOD will prepare a single closeout report with input from other NRC offices to formally document the resolution of each finding. (2)

Part III

Investigation Support Staff

The Commission may establish an Investigation Support Staff (ISS) that shall be proposed by the Executive Director for Operations (EDO). If established by the Commission, the 155 coordinates the Accident Review Group (ARO) and the NRC staff support activities for the Commission for the duration of the investigation. The ISS is supervised by the Director, ISS who is appointed by and receives direction and supervision from the Commission. (1)

The responsibilities of the Director, 155, include the following: (2)

Supports the Commission in its selection of the Director, ARG. and its approval of the members, including individuals outside the NRC, and supports development of the ARG charter. (a)

Coordinates with headquarters and regional offices to provide the administrative and technical support necessary for the ARG to meet its objectives and schedule. (b)

Coordinates with the Director, Office of Administration, to provide support necessary to publish an ARG report as a document in the NUREG-series. (c)

Coordinates with headquarters and regional offices to support development and Commission approval of NRC followup actions to address the findings of the ARO report. (d)

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