NOT MEASUREMENT

SENSITIVE

DOE-STD-1058-93
February 1993

DOE STANDARD

GUIDE TO GOOD PRACTICES FOR

DEVELOPING AND CONDUCTING CASE
STUDIES

U.S. Department of Energy FSC 6910

Washington, D.C. 20585

DISTRIBUTION STATEMENT A. Approved for public release; distribution is unlimited.

This document has been reproduced directly from the best available copy.

Available to DOE and DOE contractors from the Office of Scientific and
Technical Information, P.O. Box 62, Oak Ridge, TN 37831.

Available to the public from the National Technical Information Service, U.S.
Department of Commerce, 5285 Port Royal Rd., VA 22161.

Order No. DE93012982

 DOE-STD-1058-93

FOREWORD

The purpose of this Department of Energy (DOE) Guide to Good Practices for
Developing and Conducting Case Studies is to provide Department of Energy contractor
organizations with information that can be used in the development and use of case studies as a
method to incorporate operating experiences into the training program. Contractors are not
obligated to adopt all parts of the document. Rather, they can use the information in this
guide to develop programs that apply to their facility.

This guide can be used as an aid design, development, and conducting of case studies
for use in the training program. This guide can be used for both the initial and continuing
training programs.

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CONTENTS

FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.3 Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.4.1 What Are Case Studies, and Why Use Them? . . . . . . . . . . . . . . . . . 4

1.4.2 Adult Learners and the Case Study . . . . . . . . . . . . . . . . . . . . . . . . . 4

2. TYPES OF CASE STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3. SOURCES OF INFORMATION FOR CASE STUDIES . . . . . . . . . . . . . . . . . . . . . . . 9

4. DEVELOPING CASE STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

4.1 The Case Study Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

4.2 The Case Study Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

4.3 The Case Study Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

4.4 Writing the Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

4.5 Providing Case Study Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.6 Providing Information on Facility-Specific Actions . . . . . . . . . . . . . . . . . . . . 16

4.7 Incorporating the Case Study Into the Lesson Plan . . . . . . . . . . . . . . . . . . . . 16

4.8 Piloting the Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

4.9 Review and Approval of the Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

5. CONDUCTING CASE STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

5.1 Instructor Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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5.2 Trainee Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

5.3 Questioning Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

APPENDIX A TYPES OF CASE STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1

APPENDIX B CASE STUDY EXAMPLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1

TABLE

Table 1. Action verbs that lend themselves to case studies . . . . . . . . . . . . . . . . . . . . . . . . . 3

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1. INTRODUCTION

“Experience keeps a dear school,” said Benjamin Franklin. “A fool can learn in no
other.” Learning from experience is often very costly to a facility: in terms of injured
personnel, damaged equipment, and wasted manhours. Learning from the experience gained
at the facility and from industry can prevent repeating costly mistakes. This guide contains a
method for learning from experience to prevent mistakes from occurring. That method is the
case study. This guide describes how to develop and present case studies. This guide should
give the instructional developer some ideas on the best kind of case study to use as well as
providing examples of the various types of case studies.

1.1 Purpose

Training on industry and inhouse operating experiences should occur throughout the
training program to help prevent recurring unsafe events and to curb dangerous trends.
Experiences from the facility or from other industries should be incorporated in a manner
that is systematic and timely in conveying useful information. Case studies provide a means
to organize this information and present it to the trainees in a systematic way. By having
trainees analyze and discuss case studies, the learning experience is accelerated because the
trainees are actively involved in the learning process.

1.2 Background

This DOE Guide to Good Practices for Developing and Conducting Case Studies was
developed on the basis of experience from the nuclear industry and incorporates information
from various resources that include: reports prepared for the Nuclear Regulatory
Commission (NRC) and the Department Of Energy; information gathered from training
manuals and training handbooks; and methods successfully implemented by DOE and
commercial nuclear facilities.

Case studies have been used for many years as an alternative to the lecture method.
The first case studies were developed on the Harvard University campus. The Harvard
Method has been used to report actual situations and analyze case reports since the 1880s.
This nondirective way of helping students to think for themselves has won acceptance in law,
medicine, business administration, and social work.

One of the lessons learned from the Three Mile Island (TMI) accident was that
personnel in the nuclear industry did not have a means to share information learned from

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events at other plants. As training programs and methods have improved since the TMI
accident, the nuclear industry has relied more and more on the case study to teach the lessons
learned from industry events. By reviewing actual plant events in detail, trainees are
challenged with analyzing actual situations and problems.

1.3 Application

Case studies can be used in training programs for managers and supervisors, control
room teams, maintenance personnel, process operators, and other disciplines at DOE
facilities. This method works well in initial and continuing training programs. Case studies
can be developed for various issues that include technical problems, plant events,
management concerns, or a combination of these. Commercial utilities and other
organizations have developed case studies on a variety of subjects.

DOE facilities subject to training accreditation can use this guide to assist them in
meeting the applicable Training Accreditation Program (TAP) performance criteria contained
in the Training Program Manual (TAP 1). Specifically, using case studies will help meet
Criteria 6.6 and 9.2. Criteria 6.6 states in part “Continuing training content
includes...training on...facility and industry events....” Criteria 9.2 states, “Training
activities encourage direct trainee participation in the learning process.” (The DOE Guide to
Good Practices for Continuing Training can provide information and methods useful in the
development and implementation of continuing training programs.)

Facilities can use the methods and information presented in this guide to improve
existing training programs and comply with DOE Order 5000.3A, “Occurrence Reporting
and Processing of Operations Information.” DOE Order 5000.3A Section 8.c(2) states in
part:

“Contractors for each facility or group of facilities shall collect and

disseminate to their personnel the operations information obtained from their
facilities and the lessons to be learned from this information.... The Facility
Manager should...identify good practices and lessons learned from other
facilities that can be used in his/her facility.”

In addition, DOE Order 5480.20, “Personnel Selection, Qualification, Training, And

Staffing Requirements At DOE Reactor And Non-Reactor Nuclear Facilities” contains
requirements for incorporation of industry operating experience, training on identified
performance problems, and other subjects that must be taught to certain Category A and B
nuclear facility personnel.

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1.4 Discussion

In the Performance-Based Training Manual (TAP 2), the design phase is described as
the place where “... information collected during the analysis phase (is used) to provide a
‘blueprint’ for developing...training programs.” The manual goes on to state that one of
“...the major outputs of the design phase are the learning objectives....”

Information on how to write learning objectives can be found in the DOE Guide to
Good Practices for Developing Learning Objectives.

After the learning objectives have been written, the instructional developer should
consider what instructional strategies (i.e., the settings and methods) should be used to teach
the objectives. Whether designing lesson plans for initial or continuing training, or revising
existing lesson plans, the instructional developer has many choices to make when considering
the instructional strategy of a lesson. A case study is but one of those strategies that can be
used.

When reviewing the objectives, an instructional developer should look for key words
that indicate a higher-level objective that may be suitable for a case study. Higher-level
learning objectives are those objectives that require a trainee to use problem-solving skills
rather than simple recall or memorization. Table 1 contains examples of action verbs that
lend themselves to using a case study.

Table 1. Action verbs that lend themselves to case studies.

OBJECTIVE HIGHER LEVEL CLASSIFICATIONS

DOMAIN AND KEY WORDS
DIAGNOSIS analyze, classify, compare, detect, diagnose,
examine, identify, recognize, troubleshoot

COGNITIVE DEVELOPMENT conclude, derive, design, develop, discuss,

formulate, organize, plan, predict, relate,
restate, solve, summarize, write
EVALUATION assess, decide, choose, defend, determine,
evaluate, rate, select

PROMOTION advocate, model, support

AFFECTIVE
DEFENSE argue, debate, defend, prevent

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Before an instructional developer can develop and use case studies, an understanding
of what they are and why they are useful is necessary.

1.4.1 What Are Case Studies, and Why Use Them?

A case study is a presentation of real or hypothetical situations used to stimulate

analytical and problem solving approaches. The key words to note here are “...analytical
and problem solving approaches.” By design, a case study requires a trainee to analyze the
situation and solve the problems using previous or newly acquired knowledge or skills.

An instructional developer can help motivate the trainees to learn by designing lessons
that allow them to participate in the learning activity. Trainee interest is aroused and
maintained by making them active rather than passive participants. The trainees examine
situations that have actually occurred, could have occurred, or are occurring. The trainees
are given specific facts about events and are then required to think through the case study to
arrive at a conclusion.

Case studies can help the trainee develop judgment skills and the ability to think
independently and maturely, which in turn prepares them for job experiences. Trainees can
make comparisons and draw their own conclusions to arrive at a solution in an environment
that is risk-free. They also learn how to listen better and improve their ability to convey
ideas.

Often, the trainees work in a group to analyze a case study. This helps the trainee to
establish a give and take attitude. Trainees see that people approach the same problem
differently; that there is no “one correct way” to solve problems. Trainees develop a
willingness to see problems from all points of view.

1.4.2 Adult Learners and the Case Study

Adult learners bring many characteristics to the learning environment. These

characteristics, (e.g., rate of learning, experience, relevance of the training to the job, need
for self-direction, differences in learning styles, and a need for problem-centered situations)
are described in detail in many different textbooks on learning theory. These characteristics,
and how they apply to case studies, are briefly summarized here.

The rate of learning of an adult can be affected by many events. For example, a
“typical adult” has been out of the classroom environment for some time. They may have
lost effective study habits, which in turn may inhibit their ability to study independently.

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Case studies may be able to overcome this problem by allowing the adult to work in a group;
each person helping the other to learn.

Trainees bring to the classroom an abundance of experiences: previous knowledge,

habits, prejudices, and so on. When designing a case study, instructional developers should
require discussion and input from the trainees to allow for their experiences.

An instructional developer may expect a trainee to retain and use the information
presented in a case study if it is shown how the information is relevant to the job. When an
adult understands and accepts the relevance of the information, they will be more open to
learning the information and transfer the learning back to the job. Instructional developers
should design a case study that incorporates plenty of examples of where, how, or when the
information presented can be used after the trainees leave the learning environment.

Adults want to be responsible for their own actions, and they want to be treated that
way. Most adults feel that they have something to contribute to learning situations, and they
want that feeling recognized. The instructional developer should consider this need for self-
direction and design the case study to encourage it in learning situations.

Because of different learning styles, some adults may learn more effectively by
reading. Others may learn by listening to a lecture. Still others may need to put their hands
on an object to understand it. Instructional developers should design case studies that
accommodate as many different learning styles as practical.

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2. TYPES OF CASE STUDIES

There are many types of case studies that are used today. No one type can be singled
out as the “best” because each type of case study has a different application. Often, more
than one type of case study could be used for the same objective. The trainer will have to
decide which type to use. Types of case studies include the following:

C Background
C Complex
C Comprehensive
C Critical Incident
C Decision
C Exercise
C In-Tray
C Live
C Participant
C Role Play
C Sequential
C Situation
C Interactive Video.

Appendix A contains a list of the types of case studies, suggested objective classifications
they could support, and a description of the case study. Appendix B provides some case
study examples.

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3. SOURCES OF INFORMATION FOR CASE STUDIES

Case studies present facts and situations. These situations are based on information
from events that have actually occurred. To obtain this information, the instructional
developer must have information resources such as:

C Inhouse events (occurrence reports, near misses, etc.)

C Occurrence Reporting and Processing System (ORPS)
C Safety Performance Measurement System (SPMS)
C DOE Office of Nuclear Safety's Operating Experience Weekly Summary
C Supplier/vendor letters and bulletins
C Nuclear Plant Reliability Data System (NPRDS) (available to production reactors
only)
C Personal experiences
C Experiences of colleagues
C Problems presented by lecturers at conferences, workshops, and training sessions
C Articles in training, personnel, and management journals
C Articles in newspapers and magazines
C Human Performance Evaluation System (HPES) Reports
C Organizational events
C Nuclear Network operating experience entries (available only to production reactors)
C DOE/NRC bulletins, information notices, and generic letters
C Case books
C National Transportation Safety Board Accident Reports.

The DOE Guide to Good Practices for Incorporating Operating Experiences describes how to
gather and process information that may be useful for case studies.

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4. DEVELOPING CASE STUDIES

The following steps and related examples illustrate the development of a

comprehensive case study.1 Where applicable, suggestions are made on how these steps
relate to the development of other types of case studies.

4.1 The Case Study Focus

The focus of a case study will be determined by the learning objective(s). This step
is the most critical one, because not meeting the learning objective equates to wasted time.
For example, the following objectives may be found in a typical facility training program:

OPERATOR LEARNING OBJECTIVE: Given a situation involving

an inplant fire, assess the plant conditions and determine a course of
action that will place the plant in a safe condition.

FIRE BRIGADE MEMBER LEARNING OBJECTIVE: Given a

situation involving unusual maintenance activities in the plant,
identify potential personnel and/or plant safety hazards and identify
how these hazards could be prevented.

Based on these objectives, the focus of the case study can be written in the case study
introduction and look like this:

A CABLE TRAY FIRE AT A COMMERCIAL NUCLEAR POWER PLANT

444444444444444444444444444444444444444444444444444444444444444444444444444444444444444U

This case study covers a cable Successfully extinguishing a fire is

tray fire at a commercial nuclear power difficult under ideal conditions;
plant. An event description of operator combining fire fighting efforts with a
actions necessary to fight the fire and plant shutdown requires forethought and
maintain control of the plant is planning.
included.

1
The complete case study used to explain the development steps can be found in Appendix B of this guide.

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For other types of case studies, the focus can be noted in the instructor's lesson plan
stating the purpose of the case study activity.

4.2 The Case Study Situation

Establish a situation that illustrates the focus of the case study. This requires the
instructional developer to draw upon actual events or their own experience to develop typical
problems. The situation should provide an appreciation that the event occurred and has the
potential to occur at the facility. The situation can be introduced in an overview of the case
study like this:

OVERVIEW resulted in high air flow rates through the

wall.
The commercial nuclear power
plant experienced a serious inplant The effects of the fire on the plant
cable tray fire. The fire was started by were almost immediate. All Unit 1
an engineer who was using a candle to emergency core cooling systems were
check for air leaks through a fire wall lost, as well as the capability to monitor
penetration seal. The fire spread and core power. To remove decay heat, low
was fought on both sides of the reactor pressure water from the condensate
building and cable spreading room wall pumps and manual operation of primary
by plant and local community fire relief valves were used until normal decay
fighting personnel. Efforts to put out heat removal systems could be made
the fire were made difficult by several operational. Control power to motor
factors including: delay in notifying operators and pump controls was
personnel of the exact location of the established using temporary jumpers to
fire, physical location of the fire in the allow the plant to be brought to a stable
cable trays, and the high differential shutdown condition. There was no
pressure between the cable spreading release of radioactivity.
room and the reactor building that

In other types of case studies, a “thumbnail sketch” of the situation can be provided
to the instructor within the lesson plan to aid in lesson preparation.

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4.3 The Case Study Symptoms

The symptoms are the basic building material of the case study. No matter what kind
of case study the instructional developer chooses, the symptoms must be provided to the
trainees. Instructional developers should provide evidence or clues that will give the
symptoms to the trainee. Depending on the trainee's experience with using case studies as
well as the learning objective the case study supports, some clues may need to be more
obvious than others. Looking at the example case study in this text, the clues and symptoms
include:

C An engineer who used a candle to check for air leaks.

C Various plant personnel who delayed notifying the control room of the fire.
C The location of the fire in an area difficult to access.
C The use of flammable materials to seal wall penetrations.
C The existence of high air flow rates through various wall penetrations.
C Cables damaged by fire that prevented automatic equipment operation.

Depending on the type of case study, you will need to provide facts or statements
from key characters that will lead the trainee toward the symptoms and training objective.
To do this, the developer may need to create story characters. Make these characters real,
with acceptable everyday names and ensure that they are human—not all bad or all good.

4.4 Writing the Case Study

The instructional developer should keep some specific points in mind when writing
the body of the case study.

C Make the narrative as concise as possible; use graphs and figures to help present the
facts.
C Case studies can date very quickly; therefore, use periods of time (e.g., one year)
rather than actual dates (e.g., September 1983).
C Provide the cause of the event, either in the body of the case study as the example
shows, or in the lesson plan for other types of case studies.
C Give factors that affected the severity of the event (i.e., what made the situation
worse).
C State the lessons learned from the event, either by writing it into the case study as in
the example, or by providing it in the lesson plan for case study types.

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Although the instructional developer should be concise, enough of a description is needed to

make the case meaningful. All aspects of the case related to the objective must be included.
In this example case study the specific points mentioned above are included in the following
excerpts.

DESCRIPTION OF THE supply and exhaust fans and will always

EVENT be toward the area of possible higher
radiation. The reactor building and
This commercial nuclear power refueling floor is the area of lowest
plant is a three-unit boiling water reactor pressure. The standby gas-treatment
site. At the time of the event, Units 1 system must exhaust air from the reactor
and 2 were in operation at 100% power. building to maintain a negative pressure.
Unit 3 was under construction. In order not to exceed the capacity of
this system, inleakage to the reactor
Activities Preceding the Fire building must be kept at a minimum.

The plant is designed so the air The refueling floor is common for
movement from one plant area to another all three reactor units. To maintain the
is controlled by proper pressure....

...operation and also the potential OR CORE SPRAY AUTOMATIC

personnel hazards associated with BLOWDOWN PERMISSIVE,""
fighting fires in electrical cabling with REACTOR WATER LEVEL
water. LOW-AUTOMATIC BLOWDOWN,"
and "CORE COOLING
Effects on Plant Operation SYSTEM/DIESEL INITIATE."

The first indication of the fire's The control room operators

effect on Unit 1 operation came observed that normal conditions of
20 minutes after the fire started with reactor water level, reactor steam pres-
the almost simultaneous annunciation sure, and drywell atmosphere pressure
of several alarms: "RESIDUAL existed, so they were confused by the
HEAT REMOVAL alarms. Over the next 8 minutes, several
events occured, including the....

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...instructed to recheck all penetrations ...After inserting the resilient

in their assigned areas. polyurethane foam into the leak, the
inspector placed the candle about
Fire in the Cable Spreading Room 1 inch from the foam to check the
success of the repaired seal. The
Cable penetrations had been airflow through the leak pulled the
sealed after initial installation but candle flame into the resilient
additional cables were often added. To polyurethane foam, which sizzled and
make an opening for additional cables, began to burn. The inspector and the
holes were punched through the wall... electrician attempted unsuccessfully to
put out the fire by breaking up....

...instrumentation was lost. Unit 2 ...not already affected. Although the sug-
reactor was placed in shutdown cooling gestion to use water was made repeatedly
about 11 hours after the fire started. by the local community fire chief, plant
personnel were concerned about the ef-
Lessons Learned fects of grounds and shorts on plant
operation and potential personnel hazards.
The inability to put out the fire
was caused, in part, by the large air Community fire fighting personnel
flow through the penetration that did not arrive at the scene until
prevented the carbon dioxide and dry approximately 45 minutes after they were
chemicals from smothering the fire. called. Part of the delay was the need
Compounding this were the fire... to....

4.5 Providing Case Study Questions

The case study should include questions for the instructor to ask the trainees. These
questions can be written within the case study as the next example shows, or within the
lesson plan for other types of case studies. These questions should be based on the learning
objectives because they ask for the correct response to be observed. The instructional
developer should provide the instructor with correct or acceptable answers in an answer key
within the lesson plan.

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QUESTIONS

C What steps are taken at your - Shift supervisor

facility to ensure the ability to - Fire brigade leader
operate equipment and valves - Fire brigade team member
locally?
C What sources of emergency
C How are the operators at your lighting and ventilation are
facility made knowledgeable of available at your facility for use at
alternate equipment power the scene of a fire? Where are
supplies and system they located?
cross-connect capabilities?
C How are the following casualty
C How is the quantity and response elements coordinated
location of breathing air packs at with the surrounding communities
your facility determined? at your facility?

C What are the immediate - Knowledge of response

individual responses to a fire at capabilities
your facility... - Compatibility of equipment
- Provisions for rapid....

4.6 Providing Information on Facility-Specific Actions

Provide information on facility-specific design or procedures that would moderate the

severity of a similar event should it occur at your facility. This information may consist of
excerpts from procedures, DOE Orders, Technical Safety Requirements (Technical
Specifications/Operational Safety Requirements), descriptions of engineered and other
corrective solutions, and so on. The next example illustrates this point.

For other types of case studies, facility-specific actions can be provided to the
instructor within the lesson plan.

4.7 Incorporating the Case Study Into the Lesson Plan

No matter which type of case study has been selected, the instructional developer
should incorporate it into new or existing lesson plans. When incorporating the case study

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FACILITY ACTIONS

Maintain high standards of Station fire watches during spark

housekeeping and cleanliness. or flame producing activities.

Obtain the proper permits for Notify the control room of casualty
cutting, welding, or flame producing conditions and location.
operations.

into the lesson plan, the instructional developer should write clear instructions to the
instructor on how to administer the case study. The instructions should include guidance on
what materials to hand out to the trainees, some questions the instructor could ask to “set the
mood” for the case study, and a summary at the conclusion of the case study.

When developing a lesson plan that will use the case study method, the instructional
developer will want to build in extra time to allow for the discussion the case study will
generate.

4.8 Piloting the Case Study

Pilot (i.e., test) the case study! This is a very important step, because the pilot will
check the case study for consistency, completeness, and acceptability. The pilot will ensure
that the desired answers to the questions develop logically during the discussion of the case
study and represent the terminal behavior required of the trainees. The pilot will also
determine if the directions for administering the case study are adequate. It is best to use a
sample of the trainee population for whom the case study was written. If this is not feasible,
allow other instructors to read it and discuss their interpretation of the case study materials.

4.9 Review and Approval of the Case Study

Once the case study has been developed, reviewed for technical and editorial
accuracy, and piloted, it should undergo a final review and approval process by facility
management. The training manager, should provide the final review. Managers of other
facility departments, especially those departments the case study will affect, should also
review and approve (or concur with) the case study. This review and approval process is
required by Criteria 8.4 of the Training Program Manual, (TAP 1).

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5. CONDUCTING CASE STUDIES

After the case study has been prepared, reviewed, and approved, it is ready to be
presented to the trainees. Both the instructor and the trainee must be properly prepared to
maximize learning with the case study.

5.1 Instructor Preparation

The case study method requires a skilled instructor. If the case study is not presented
properly, the instructor will lose many of the benefits of using the case study method. The
instructor should consider the following items prior to using a case study:

C The instructor must be completely knowledgeable about the case study to be

presented. Read the case study several times and analyze it. Develop plausible
solutions and make a list of them. Have another trainer read the case study and give
possible solutions.
C The instructor must have all of the necessary training aids and materials to facilitate
learning from the case study. This includes trainee handouts, graphs, transparencies,
video tape, reference material, etc.
C The instructor should use a lesson plan. The lesson plan should include directions for
size of work groups, class arrangement, etc.
C The instructor should review and understand the questions developed for the case
study. In addition to the prepared questions, the instructor should think of questions
to ask the trainee during the discussions of the case study. The instructor must be
able to phrase questions to stimulate discussion. The instructor should not give
his/her personal views on the case and must avoid giving the answer away—the
learning must come from the trainee's own discoveries. Section 5.3 of this guide
discusses questioning techniques that an instructor may use.

5.2 Trainee Preparation

The case study should be introduced to the trainees to ensure they understand how a
case study is used and how the discussions are conducted. Trainees can be encouraged to
examine each element of the case carefully by reflecting on the analysis process. This begins
by examining their own statements and by listening to what others say. It includes
withholding their judgment until all the facts are stated, questioning rather than making
pronouncements, and reflecting on “the whys” as well as “the whats.”

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 DOE-STD-1058-93

Trainees should be encouraged to listen to other points of view. They should support
creative approaches to solving problems. The trainees should ask the instructor, as well as
each other, questions that probe for understanding of the situation.

5.3 Questioning Techniques

The instructor who asks questions during the course of instruction is using the adult
learning concept of experience and self-direction. Questioning is an important element in the
adult learning environment. The way an instructor phrases a question will affect the trainee
response.

Good questioning techniques are especially important when using case studies. The
question an instructor asks the trainees at the beginning of the case study usually sets the tone
for the discussion that follows. The questions—What do you think? What should happen
next?—are designed to create interest in the case and to get the trainee involved. From that
time on, the instructor should act as a facilitator, monitoring and directing the group
discussion. This ensures that the trainees remain focused. If the discussion starts to stray
from the case being studied, the instructor should ask one or two questions to get the trainees
back on track. This is not to say that the instructor forces the direction of the case study.
Case study discussions should be somewhat freewheeling so as to allow the trainees to search
for the conclusions.

At the end of the case study, the instructor should ask questions that probe the
understanding of the underlying principle that is illustrated by the case study. Usually, this
is started by inviting the trainees to state their own conclusions, and based on the response
they give, the instructor should ask questions that probe their depth of understanding. For
example, the instructor may say, “That's a good response. How would you explain your
answer to someone who feels otherwise?” An instructor needs to be sensitive at this point.
As stated previously, often there is no one right answer, and the trainees may discover
another unique and valid answer to the case study.

Regardless of the answer, an instructor should provide positive feedback. If a trainee

has missed the point of the case study, don't criticize. Motivate by reinforcing the portions
of the response that is correct (e.g., The first part of your answer is a partial solution of the
problem. Can you take that idea one step farther?). If the trainee still cannot answer, use
the part of the response that was correct and redirect the question to the rest of the group
(e.g., She brought up an interesting point. Can someone add something to this?). Positive
feedback to responses will send the signal to the trainees that it is safe to present their

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thoughts, ideas, views, and solutions. This “safe feeling” will encourage more trainee
participation and increased trainee learning.

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BIBLIOGRAPHY

Armistead, C., “How Useful Are Case Studies?,” Training and Development Journal,
February 1984.

Boyd, B.B., “Developing Case Studies,” Training and Development Journal, June 1980.

DOE ORDER 5000.3A, Occurrence Reporting and Processing of Operations Information,

Washington, D.C.: United States Department of Energy, May 1990.

DOE ORDER 5480.20, Personnel Selection, Qualification, Training, and Staffing

Requirements at DOE Reactor and Non-Reactor Nuclear Facilities, Washington,
D.C.: United States Department of Energy, February 1991.

Eitington, J. E., The Winning Trainer, 2nd Edition, Houston, Texas: Gulf Publishing
Company, 1984.

Galbraith, M. W. (ed.), Adult Learning Methods: A Guide for Effective Instruction,

Malabar, Florida: Robert E. Krieger Publishing Co., Inc., 1990.

General Physics Corporation, Fundamentals of Classroom Instruction, Columbia, Maryland:

GP Courseware, 1983.

Hennecke, M. J., “Case Studies: A New Approach,” Training and Development Journal,
March 1983.

Instructional Analysis and Design Course, Idaho Falls, Idaho: Operations & Training
Technology Applications, EG&G Idaho, Inc., 1991.

Instructional Development Course, Idaho Falls, Idaho: Operations & Training Technology
Applications, EG&G Idaho, Inc., 1991.

Knowles, M., The Adult Learner: A Neglected Species, Houston, Texas: Gulf Publishing
Company, 1984.

Knox, A. B., Helping Adults Learn, San Francisco, California: Jossey-Bass Publishers,
1986.

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Kox, D.M.; Heifner, K.; Treadway, J., Bridging the Gap Between Knowledge and
Performance, presented to the American Society for Training and Development's
Technical and Skills Training Conference in Detroit, Michigan, October, 1992.

McNair, M. P. (ed.), The Case Method at the Harvard Business School: Papers by Present
and Past Members of the Faculty and Staff, New York, New York: McGraw-Hill
Book Company, Inc., 1954.

NUREG/CP-089, “Use of Case Studies in Training Nuclear Plant Personnel,” CSNI

Specialist Meeting on Training of Nuclear Reactor Personnel, Orlando, Florida, April
1987.

Seaman, D. F., R. A. Fellenz Effective Strategies for Teaching Adults, Columbus, Ohio:
Merrill Publishing Company, 1989.

Smith, B. J., Skills for Managers and New Trainers, New York, New York: John Wiley
and Sons, Inc., 1987.

United States Department of Energy Training Accreditation Program, Training Program

Manual, TAP 1, 1991.

United States Department of Energy Training Accreditation Program, Performance-Based

Training Manual, TAP 2, 1991.

United States Department of Energy, Guide to Good Practices for Continuing Training,
February 1992.

United States Department of Energy, Guide to Good Practices for Developing Learning
Objectives, July 1992.

United States Department of Energy, Guide to Good Practices for Incorporating Operating
Experiences, July 1992.

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APPENDIX A
TYPES OF CASE STUDIES

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APPENDIX A
TYPES OF CASE STUDIES

Case studies have been recognized as an excellent method to involve the trainee in the
learning process. One problem facing the instructional developer is selecting the right type of
case study to deliver that learning. There have been many books and magazine articles
written on what is the “best type” of case study. In reality, there is no one best type. The
following list of case study types have been selected from the dozens that are available to the
instructional developer. Along with each type of case study given, suggestions for use with
objective classifications (i.e., higher order objectives) have been given, as well as a
description and suggested use for the case study.

Case Study Type: Objective Classifications:

BACKGROUND DEVELOPMENT
Description and suggested uses:
The primary purpose of the background case study is to impart information, to
supply factual data or to familiarize the trainee with the wider circumstances of
a specific situation. It can be presented as a motivator to a lesson or within the
body of a lesson to illustrate a point. The instructor provides a brief description
of the case then asks the trainees questions. After the lesson presentation, a
handout giving the facts of the case, the lessons learned, facility specific actions,
and questions asked by the instructor can be distributed to reinforce the
material.

The advantage of doing this through the medium of a case study, rather than by
means of reading, is that the trainee absorbs the data more easily. It relates to a
real situation. It also has advantages for the older trainee, who needs to acquire
the data but might not be prepared to admit their ignorance if it were presented
more formally.

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Case Study Type: Objective Classifications:

COMPLEX DIAGNOSIS, EVALUATION
Description and suggested uses:
The complex case study is a variation of the situation case study (described
later), where the problem is to diagnose the underlying issues. These issues are
not easy to distinguish because they are submerged in a mass of data, much of
which is irrelevant, and because a number of more superficial issues are present
as distractions (although the superficial and underlying issues are normally
interdependent).

The complex case study can be used within a single lesson plan or spread out
through a series of lessons within a course. The complex case study is ideal
when the trainee is required to sort out and interpret data in order to make a
decision.

Case Study Type: Objective Classifications:

COMPREHENSIVE DIAGNOSIS, DEVELOPMENT, EVALUATION
Description and suggested uses:
The comprehensive case study is the most widely used case study. The
information used is drawn from real situations and must be well-researched. The
primary objective of the comprehensive case study is to help trainees learn
for themselves by independent thinking. Comprehensive case studies are best
suited for a single lesson plan. They can be written based upon a single
situation, or a combination of situations based on the same theme.

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Case Study Type: Objective Classifications:

CRITICAL INCIDENT DIAGNOSIS, EVALUATION
Description and suggested uses:
The critical incident case study is sometimes known as a jigsaw case study.
Here, the trainee is presented with a small amount of information about a
situation. Additional data is supplied by the instructor over time and may take
the form of handouts or verbal descriptions. Once all of the data is received, the
case situation can be understood, and once understood often leads to
suggestions for action. This type of case provides an opportunity to develop the
skills of “asking the right questions.” This type of case study is appropriate for
training facility operators. It would help them develop the diagnostic skills
needed for unusual events or emergency situations. The critical incident case
study can be presented in the form of an exercise within a lesson plan. A
technique for this kind of exercise is to break the trainees into teams. Some of
the teams are given the true facts of a situation and should reach similar
conclusions. The other teams are given slightly distorted facts that, without
careful consideration, can lead to conclusions different from the other teams.
This difference will generate discussions allowing the trainees to contrast and
compare their conclusions in order to arrive at a consensus.

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Case Study Type: Objective Classifications:

DECISION DEVELOPMENT, EVALUATION, PROMOTION, DEFENSE
Description and suggested uses:
The decision case study can be used as an exercise within a lesson plan, or as
an evaluation tool to measure whether the trainees have achieved the objective.
This type of case study can be combined with a role play to enhance the
learning experience. The decision case study requires the trainee to do more
than to acquire and manipulate data or to provide an analysis of a situation.
Here, the trainee has to exercise judgment and state what should be done in the
circumstances described. This requires the formulation of an action plan.

The decision case study is useful when the instructional developer wants to
improve creative thinking, judgment, or attitudes. This is also an excellent
method to gauge trainee performance under various situations. It provides a
risk-free atmosphere for the trainees to test their actions.

Case Study Type: Objective Classifications:

EXERCISE DIAGNOSIS, DEVELOPMENT, EVALUATION
Description and suggested uses:
This type of case study relates to real-life situations. Similar to the background
case study method, the practice of certain techniques, particularly those
involving quantitative manipulations (e.g., chemistry dilution or concentration
problems, startup rate problems, shielding problems, criticality problems) are
made easier if the data is presented in case form. The trainee can see that the
manipulation relates to a necessary job skill, rather than being purely an
academic exercise. This is important especially when instructing adult learners.
This type of case study is equally effective in classroom, laboratory, or on-the-
job settings.

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Case Study Type: Objective Classifications:

IN-TRAY DIAGNOSIS, DEVELOPMENT, EVALUATION,
PROMOTION, DEFENSE
Description and suggested uses:
The in-tray case study is a variation of the decision-type case study and consists
of a number of documents that managers or supervisors might find in their in-
trays. Some background information is provided, and the trainees are allowed a
limited time to determine and record their actions on each of the documents
provided. This type of case study closely approximates a real-life supervisory
function. The in-tray case study is very useful for improving analytical skills,
promoting creative thinking, and practicing decision making. For example, it can
be used to train on facility policies and evaluating learning objectives in the
affective domain. The in-tray case study can be used as an exercise within a
single lesson plan, or a series of exercises throughout a course.

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Case Study Type: Objective Classifications:

LIVE DIAGNOSIS
Description and suggested uses:
The live case study is one of the more unique types of case studies in use. The
material for a live case study comes from events that are occurring at the
present time. Often, nothing more than a newspaper article is used to provide
the trainees with the case study information. The instructor provides questions
for thought and to prompt a discussion. The answers are truly unknown when
this case is presented. Only after a few days can the trainee's conclusions be
compared with the actual decisions made. This is usually found in a follow-up
newspaper article, or industry publication. This type of case study can be used
in classes that last several weeks (such as reactor operator qualifications), or for
requalification programs.
Because the information for a live case study is based on current events, it is
difficult to plan for and write into a lesson plan.

To use a live case study, give the trainees up-to-date factual information to start
with. During the remainder of the class, provide an interim problem-solving
exercise. Finally offer opportunities to compare and appraise a variety of
solutions for the problem analyzed (i.e., comparing hypothetical solutions
worked out in the study group against the actual solutions that have been
applied).

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Case Study Type: Objective Classifications:

PARTICIPANT DEVELOPMENT, PROMOTION, DEFENSE
Description and suggested uses:
The participant case study is a variation of the conventional case study. The
idea is to have the trainees develop and present a case study to the group. The
trainees can readily identify with this type of case since it is being conveyed
(normally) by one of their peers. The advantages of this approach include
greater trainee involvement and interest, cases which are complex and
challenging, and increased responsibility by trainees to contribute materials for
the learning experience, with a corresponding reduction in the dependency on
the trainer who ordinarily “does it all.” A participant case study can promote
interaction and teamwork since the cases brought in by the trainees often relate
to problems in their work environment or area.

This type of case study can be used as a final exercise within a course, where
the information has been presented to the trainees over the entire course.

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Case Study Type: Objective Classifications:

ROLE PLAY DIAGNOSIS, DEVELOPMENT, EVALUATION,
PROMOTION, DEFENSE
Description and suggested uses:
With a role play case study, the trainees participating receive outlines of the
roles that they have agreed to assume and are then free to develop the
characterization of the roles as they see fit. The roles are written on the basis
of actual incidents with the characters being the participants in the incident. A
brief summary of the incident is presented by the instructor to “set the scene”
before the trainees begin the role play. Role plays usually are not scripted;
consequently, the outcome cannot be predetermined. When role playing is
used, it generates a near-live case study for subsequent analysis and an
opportunity for the players to experience the feelings of being themselves in the
case situation, in which they can test the validity of their views. Role playing is
an excellent way to teach and evaluate affective learning objectives.

Simulator scenarios are a form of role play, because the simulator is set to
provide a certain facility condition and the trainees are trained and evaluated on
the required responses.

Role plays can be combined with other types of case studies to enhance the
learning. Role plays can be used anywhere within a lesson plan: as a motivator,
an internal transition, or for evaluation.

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Case Study Type: Objective Classifications:

SEQUENTIAL DIAGNOSIS, DEVELOPMENT, EVALUATION
Description and suggested uses:
The technique in this type of case study is to “stop the action” at a critical point
in the event so that the trainees can predict outcomes or suggest courses of
action. The event is then continued, and an analysis made of the reasons for
the differences between the predictions and what actually happened. This
technique is an excellent way to improve the trainee's analytical thinking. It
can be effectively employed at facilities using simulators. The sequential case
study can be combined with other case studies such as an exercise case study
or role play for enhanced learning.

Case Study Type: Objective Classifications:

SITUATION EVALUATION
Description and suggested uses:
This case study is similar to the comprehensive case study. This type of case
describes events that may be seen either as a success or as a failure. While the
issues are usually fairly clear, they are often not those stated by the characters
in the case. For example, it could relate a situation where one participant
inadvertently discriminates against another participant. This type of case study
is excellent for improving analytical thinking. Trainees studying the case learn to
critically examine such statements in the light of the other evidence presented.
They can also be used as preventive training for negative events (i.e, If
personnel are informed of adverse events and understand the causes, they might
not make the same mistake themselves). A situation case study can be written
anywhere within a lesson plan.

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Case Study Type: Objective Classifications:

INTERACTIVE VIDEO DIAGNOSIS, EVALUATION
Description and suggested uses:
Technology has merged the computer with the videodisc to produce a powerful
instructional tool. This technology allows the instructional developer to bring
simulation into the classroom, providing realistic, hands on training for the
trainee. Interactive video can simplify ideas and events so that the trainees “get
the message” with relative ease (e.g., this is helpful to those trainees who have
difficulty learning the information from reading). For this type of case study, the
simulation can be that of a process, system, or component, set up so that
events that have occurred in the past can be repeated for the trainees. The
trainees interact with the system and respond to the situation presented. This
type of case study helps to build diagnostic skills and analytical thinking.

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APPENDIX B
CASE STUDY EXAMPLES

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APPENDIX B
CASE STUDY EXAMPLES

THE COMPREHENSIVE CASE STUDY

The example comprehensive case study on the next page was used to train personnel
in the commercial nuclear industry. Because of the length of the comprehensive case,
trainees may need to spend considerable time (as much as two or three hours) in preparation
for the case discussion session. The discussion is very nondirective, with the instructor's
role being that of catalyst, encourager, climate-setter, devil's advocate, issue sharpener,
referee, etc., rather than that of expert, lecturer, authority figure, and the like. The
instructor's technique to start the discussion is often a simple question: “What seems to be
going on here?”

The group typically will identify many issues in the case since it is so comprehensive
and diverse. A major goal is for the trainees to see the “big picture,” the relationships of
events, the internal and external forces at work, the role of personality in decision making,
and so forth. Learning takes place largely because of the different views of the group.

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A CABLE TRAY FIRE

AT A COMMERCIAL NUCLEAR POWER PLANT

his case study covers a cable tray fire power. To remove decay heat, low pressure
T at a commercial nuclear power plant.
An event description of operator actions
water from the condensate pumps and
manual operation of primary relief valves
necessary to fight the fire and maintain were used until normal decay heat removal
control of the plant is included. systems could be made operational. Control
power to motor operators and pump
Successfully extinguishing a fire is controls was established using temporary
difficult under ideal conditions; combining jumpers allowing the plant to be brought to
fire fighting efforts with a plant shutdown a stable shutdown condition. There was no
requires forethought and planning. release of radioactivity.

OVERVIEW DESCRIPTION OF THE EVENT

he commercial nuclear power plant his commercial nuclear power plant is

T experienced a serious inplant cable
tray fire. The fire was started by an
T a three-unit boiling water reactor site.
At the time of the event, Units 1 and 2 were
engineer who was using a candle to check in operation at 100% power. Unit 3 was
for air leaks through a fire wall penetration under construction.
seal. The fire spread and was fought on
both sides of the reactor building and cable Activities Preceding the Fire
spreading room wall by plant and local
community fire fighting personnel. Efforts The plant is designed so the air
to put out the fire were made difficult by movement from one plant area to another is
several factors: delay in notifying personnel controlled by supply and exhaust fans and
of the exact location of the fire, physical will always be toward the area of possible
location of the fire in the cable trays, and the higher radiation. The reactor building and
high differential pressure between the cable refueling floor is the area of lowest
spreading room and the reactor building that pressure. The standby gas-treatment system
resulted in high air flow rates through the must exhaust air from the reactor building to
wall. maintain a negative pressure. In order not
to exceed the capacity of this system,
The effects of the fire on the plant inleakage to the reactor building must be
were almost immediate. All Unit 1 kept at a minimum.
emergency core cooling systems were lost,
as well as the capability to monitor core

B-5
 DOE-STD-1058-93

The refueling floor is common for all Fire in the Cable Spreading Room
three reactor units. To maintain the proper
pressure conditions, an airtight partition was Cable penetrations had been sealed
constructed between operating Units 1 and after initial installation but additional cables
2, and Unit 3, while Unit 3 was under were often added. To make an opening for
construction. It was necessary to determine additional cables, holes were punched
that the standby gas-treatment system could through the wall penetration sealing
handle the added inleakage from the Unit 3 materials and fire stop with a wooden stick.
reactor building before the partition between This process resulted in pieces of
Units 2 and 3 could be removed. Leakage polyurethane and flameastic (fire retardant
tests run on the Units 1 and 2 reactor material) being knocked onto the cables on
buildings indicated that leakage had to be both sides of the penetration.
reduced to a maintaining inleakage within
the requirements of the Units 1 and 2 In the early afternoon, an inspector
technical specifications when the partition and an electrician were checking cable
was removed. penetrations through the wall between the
cable spreading room and the Unit 1 reactor
The program undertaken to reduce building. The inspector was using a candle
leakage required that all leaks be identified flame to detect air leaks. The inspector
and listed, that leaks be sealed, and that detected a strong air leak in the penetration
work be verified and signed off by an for the second tray from the bottom on the
engineer. The method for detecting air west row. The electrician experienced
leaks was left to the discretion of the difficulty reaching the penetration to seal it
engineer in charge. Several methods had because it was recessed into the wall farther
been employed including smoke devices, than he could reach. The inspector
soap solutions, and candles. The movement volunteered to seal the leak for the
or flickering of a candle flame was an electrician. The electrician handed him
especially effective method for locating pieces of resilient polyurethane foam sealing
leaks in dimly lighted areas and became the material that the inspector inserted into the
method most used. As the number of leaks hole. After inserting the resilient
was reduced, the differential pressure across polyurethane foam into the leak, the
the walls increased and penetrations that inspector placed the candle about 1 inch
originally did not leak began to permit from the resilient polyurethane foam to
leakage. Therefore, the inspectors, check the success of the repaired seal. The
accompanied by electricians who sealed airflow through the leak pulled the candle
leaking penetrations as they were flame into the resilient polyurethane foam,
discovered, were instructed to recheck all which sizzled and began to burn. The
penetrations in their assigned areas. inspector and the electrician attempted
unsuccessfully to put out the fire by

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breaking up and smothering the burning system. After the carbon dioxide system
material. Realizing the fire was progressing had been operated, the assistant shift
beyond their ability to control, the engineer checked the spreading room and
electrician called for fire extinguishers. The found that the fire was still burning because
fire burned for about 1 minute before the the ventilation system had not been secured.
first carbon dioxide fire extinguisher
arrived. The entire contents of three carbon Organized fire fighting efforts were
dioxide extinguishers, two of which were delayed because the control room did not
only partially filled, were emptied on the know the exact location of the fire. An
fire without effect because of the air flow assistant shift engineer located the
across the penetration. construction workers fighting the fire in the
reactor building and called the control room,
The inspector realized that the fire while another assistant shift engineer in the
had spread to the reactor building side of the reactor building reported the cable
wall, and two construction workers who spreading room fire to the control room.
were in the area left the spreading room for
the reactor building to fight that fire. On Fifty minutes after the start of the fire,
their way to the reactor building they fire fighting efforts were underway on both
informed a public safety officer of the fire sides of the wall but met with little success
in progress in the Unit 1 reactor building. in stopping the spread of the fire. The
The public safety officer called the control assistant shift engineer in charge in the
room and reported the fire, 15 minutes after reactor building called for the assistance of
it had started. a nearby community fire department. These
fire fighting personnel arrived on the scene
As the engineer prepared to discharge after the fire had burned for almost an hour
a fourth extinguisher, the spreading room and a half. Fire fighting continued in the
carbon dioxide system alarm was sounded cable spreading room using portable carbon
and all workers evacuated the spreading dioxide and dry chemical extinguishers for
room. Twenty minutes after the fire started almost three hours when a near continuous
and after ensuring that no workers were in application of dry chemical and carbon
the spreading room, an assistant shift dioxide agents extinguished the cable
engineer attempted to initiate the cable spreading room fire.
spreading room's total flooding carbon
dioxide system from outside the cable Fire in the Reactor Building
spreading room, but was unable to do so
because it had been deenergized while When the two construction workers
workmen were in the spreading room. The arrived at the penetration in the reactor
assistant shift engineer restored the electrical building, they discovered the fire had spread
power and initiated the carbon dioxide into the cable tray system about 20 feet

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 DOE-STD-1058-93

above the floor. Their attempts at were concerned about the effects of grounds
extinguishing the fire were unsuccessful. and shorts on plant operation and also the
When the assistant shift engineer arrived at potential personnel hazards associated with
the scene, he took charge of the fire-fighting fighting fire in electrical cabling with water.
efforts and evacuated all construction
workers from the reactor building. Heavy Effects on Plant Operation
smoke reduced area visibility and made the
use of breathing apparatus necessary. An The first indication of the fire's effect
hour and ten minutes after the fire started, on Unit 1 operation came 20 minutes after
all ac lighting in the reactor building was the fire started with the almost simultaneous
lost. Soon after lighting was lost in the annunciation of several alarms:
reactor building, the decision was made to “RESIDUAL HEAT REMOVAL OR
concentrate on fighting the fire in the cable CORE SPRAY AUTOMATIC
spreading room. This was necessary BLOWDOWN PERMISSIVE,”
because the cable spreading room fire was “REACTOR WATER LEVEL
beginning to affect the operability of plant LOW-AUTOMATIC BLOWDOWN,” and
systems and because the control room was “CORE COOLING SYSTEM/DIESEL
located directly above the cable spreading INITIATE.”
room. Consequently, limited fire fighting
took place in the reactor building. When the The control room operators observed
fire in the cable spreading room was that normal conditions of reactor water
extinguished four hours after the start of the level, reactor steam pressure, and drywell
fire, the assistant shift engineer, who had atmosphere pressure existed, so they were
been directing activities in the cable confused by the alarms. Over the next
spreading room, took charge of fire fighting 8 minutes, several events occurred,
in the reactor building. Because of limited including the automatic starting of residual
visibility, wires and ropes were used as heat removal and core spray pumps, the
guides by fire fighting personnel. high-pressure coolant-injection pump, and
Eventually, temporary dc lighting was the reactor core isolation coolant pump. In
installed. Teams of two to three people addition, control board indicating lights
were relayed into the fire area to discharge were randomly glowing brightly, dimming,
fire extinguishers and then return. Water and going out; numerous alarms occurred;
was not used as an extinguishing agent until and smoke came from beneath Panel 9-3,
later that evening, seven hours after the fire which is the control panel for emergency
started. After water was continuously core cooling systems. The operators shut
applied for 10 minutes, down equipment that was not needed, such
the fire in the reactor building was as the residual heat removal and core spray
extinguished. Water was initially not used pumps, only to have them restart again
to fight the fires because plant personnel automatically.

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 DOE-STD-1058-93

When reactor power was affected by from Unit 2. During this period, the reactor
an unexplained runback of the reactor water level dropped from its normal 201
recirculating pumps, the shift engineer inches to 48 inches above the top of the
instructed the operator to reduce active fuel. To recover water level, water
recirculating pump loading and scram the was added to the reactor through the
reactor. While this was being done, the feedwater bypass valve from the condensate
recirculating pumps tripped off. The reactor booster pump. Water level went too high
was scrammed by the operator 30 minutes because control of the bypass valve had
after the fire started. been lost, so an auxiliary unit operator was
sent to manually throttle the valve. Nearly
Operators confirmed that the reactor four hours after the fire started, four
control rods were fully inserted. Thirty-five auxiliary unit operators working in pairs
minutes after the fire started the were successful in isolating faulted residual
turbine-generator was manually tripped. heat removal circuits to get the residual heat
One minute later, all capability to monitor removal system aligned. The residual heat
core power was lost as the vital power removal system was not started until early
supply electrical boards were lost. In the next morning, 13 hours after the fire
addition, all emergency core cooling started, because it could not be confirmed
systems were lost because their that the system was filled with water.
motor-operated valves lost power and could Sixteen hours after the fire started,
not be operated remotely. All of the shutdown cooling had been established,
outboard main steam isolation valves shut, suppression pool cooling continued, and
isolating one main condenser as a heat sink. essential plant instrumentation had been
Because reactor pressure increased rapidly restored. Nearly all of these activities were
to 1100 psig, the control room operators accomplished as a result of operator actions
took manual control of the main steam relief locally. Temporary power supplies, manual
valves to reduce pressure by cycling valve operation, and use of temporary
pressure between 850 and 1080 psig. procedures were typical conditions because
Owing to the almost constant blowdown of of the fire damage. The effects on Unit 2
reactor pressure that added heat to the were less severe; however, the reactor
suppression pool, suppression pool cooling depressurized because of a suspected stuck-
became essential 40 minutes after the fire open relief valve and some vessel level
started, but the residual heat removal instrumentation was lost. Unit 2 reactor
system, which is normally used, was was placed in shutdown cooling about
unavailable because of the electrical board 11 hours after the fire started.
losses. The next 30 minutes were spent
trying to get the shutdown buses powered
either by the running diesel generators or

B-9
 DOE-STD-1058-93

Lessons Learned QUESTIONS

The inability to put out the fire was C What steps are taken at your facility
caused, in part, by the large air flow through to ensure the ability to operate
the penetration that prevented the carbon equipment and valves locally?
dioxide and dry chemicals from smothering
the fire. Compounding this were the fire C How are the operators at your facility
fighters' difficulty in seeing exactly what was made knowledgeable of alternate
burning and working in the confined spaces, equipment power supplies and system
which made access to the affected areas cross-connect capabilities?
difficult.
C How are the quantity and location of
The use of water at an early stage breathing air packs at your facility
would have extinguished this fire and determined?
prevented the loss of circuits not already
affected. Although the suggestion to use C What are the immediate individual
water was made repeatedly by the local responses to a fire for the following
community fire chief, plant personnel were personnel?
concerned about the effects of grounds and
shorts on plant operation and potential - Person discovering the
personnel hazards. casualty
- Shift supervisor
Community fire fighting personnel did - Reactor operator
not arrive at the scene until approximately - Shift technical advisor
45 minutes after they were called. Part of - Fire brigade leader
the delay was the need to process temporary - Fire brigade team member.
radiation monitoring badges.
C What sources of emergency lighting
The community fire department and ventilation are available for use at
special water hose nozzle for electrical fires the scene of a fire? Where are they
was not compatible with the plant's hose. located?

A fire watch, who normally has no

other duties but to watch for potential fires,
had not been assigned.

B-10
 DOE-STD-1058-93

C How are the following casualty similar casualty?

response elements coordinated with
the surrounding communities? FACILITY ACTIONS

- Knowledge of response Maintain high standards of

capabilities housekeeping and cleanliness.
- Compatibility of equipment
- Provisions for rapid facility Obtain the proper permits for cutting,
access welding, or flame producing operations.
- Definition of roles and
responsibilities Stationing fire watches during spark
or flame producing activities.
C What additional steps need to be
taken at your facility to enhance the Promptly notify the control room of
operator's ability to deal with this or a casualty conditions and location.

B-11
 DOE-STD-1058-93

THE BACKGROUND CASE STUDY

The background case study is ideal for use within a lesson plan as a motivator, as an
introduction to a new objective or lesson topic, or as a means for measuring trainee's
comprehension of the lesson material. The case study is presented to the trainees by the
instructor and then discussed. After the discussion, a handout similar to the one on page
B-13 can be distributed to the trainees as reinforcement of the case studies lessons learned.

B-13
 DOE-STD-1058-93

A CABLE TRAY FIRE AT A COMMERCIAL NUCLEAR POWER

PLANT

A commercial nuclear power plant experienced a serious inplant cable tray fire.
The fire was started by an engineer who was using a candle to check for air leaks through
a fire wall penetration seal. The fire spread and was fought on both sides of the reactor
building and cable spreading room wall by plant and local community fire fighting
personnel. Efforts to put out the fire were made difficult by several factors: delay in
notifying personnel of the exact location of the fire, physical location of the fire in the cable
trays, and the high differential pressure between the cable spreading room and the reactor
building that resulted in high air flow rates through the wall.

The effects of the fire on the plant were almost immediate. All Unit 1 emergency
core cooling systems were lost, as well as the capability to monitor core power. To remove
decay heat, low pressure water from the condensate pumps and manual operation of
primary relief valves were used until normal decay heat removal systems could be made
operational. Control power to motor operators and pump controls was established using
temporary jumpers allowing the plant to be brought to a stable shutdown condition. There
was no release of radioactivity.

A. Lessons Learned

C The inability to put out the fire was caused, in part, by the large air flow through
the penetration that prevented the carbon dioxide and dry chemicals from
smothering the fire. Compounding this were the fire fighters' difficulty in seeing
exactly what was burning and working in the confined spaces, which made
access to the affected areas difficult.

C The use of water at an early stage would have extinguished this fire and
prevented the loss of circuits not already affected. Although the suggestion to
use water was made repeatedly by the local community fire chief, plant
personnel were concerned about the effects of grounds and shorts on plant
operation and potential personnel hazards.

C Community fire fighting personnel did not arrive at the scene until approximately
45 minutes after they were called. Part of the delay was the need to process
temporary radiation monitoring badges.

B-15
 DOE-STD-1058-93

C The community fire department special water hose nozzle for electrical fires was
not compatible with the plant's hose.

C A fire watch, who normally has no other duties but to watch for potential fires,
had not been assigned.

B. Questions and answers

1. What are the immediate individual responses to a fire for the following personnel?

Person discovering the casualty. Report it to the Control Room at

________.

Shift Supervisor. Notify all facility personnel, the fire department,

and security.

Reactor Operator. If necessary, scram the reactor. Carry out the

directions of the control room supervisor.

Shift Technical Advisor. Monitor the situation and advise the

control room supervisor as necessary.

Fire Brigade Leader. Report to the equipment locker and assemble

fire party. Coordinate fire fighting efforts. Keep the control room
informed.

Fire Brigade Team Member. Report to the equipment locker and

proceed as directed by the fire brigade leader.

2. How are the following casualty response elements coordinated with the
surrounding communities?

Knowledge of response capabilities. Contained in the Fire and

Safety Manual.

Compatibility of equipment. Contained in the Fire and Safety

Manual.

Provisions for rapid facility access. Contained in the Facility

Security Manual.

Definition of roles and responsibilities. Contained in the Fire and

Safety Manual and stated in the letter of agreement with the
State Department of Public Safety.

3. What additional steps need to be taken at your facility to enhance the operators'
ability to deal with this or a similar casualty? (List your ideas.)

C. Actions to take to minimize the effects of this kind of event at the facility

B-16
 DOE-STD-1058-93

1. Maintain high standards of housekeeping and cleanliness

2. Obtain the proper permits for cutting, welding, or flame producing operations

3. Stationing fire watches during spark or flame producing activities

4. Promptly notify the control room of casualty conditions and location.

B-17
 DOE-STD-1058-93

CONCLUDING MATERIAL

Review Activities: Preparing Activity:

DOE Field Offices DOE-NE-73

AD AL
DP CH Project Number:
EH ID
EM NV 6910-0027
ER OR
NP RL
NS SR
RW SAN
RF

Facilities
ANL-W
BNL
EG&G Idaho
EG&G Mound
EG&G Rocky Flats
LLNL
LANL
MMES
ORAU
REECo.
WHC
WINCO
WEMCO
WSRC