IR 05000010/1982010
| ML20028B728 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 05/31/1982 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20028B719 | List: |
| References | |
| 50-010-82-10, 50-10-82-10, 50-237-82-14, 50-249-82-15, NUDOCS 8212030185 | |
| Download: ML20028B728 (47) | |
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i U. S. NUCLEAR REGULATORY COMMISSION
REGION III
SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE
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Commonwealth Edison Company Dresden Nuclear Power Station, Units 1, 2, and 3 Docket Nos. 50-10; 50-237; 50-249 Inspection Reports No. 50-10/82-10; 50-237/82-14; 50-249/82-15 Assessment Period July 1, 19E0 to December 31, 1981 i
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i May 1982 8212030185 821201 POR ADOCK 05000010
ERRATA SHEET Facility: Dresden Nuclear Power Station SALP Report No.: 50-10/82-10; 50-237/82-14; 50-249/82-15 Page Line Now Reads Should Read v
Management weaknesses Management weaknesses expressed
expressed
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effective The resources effective. The resources vi
specific licensed attention specific licensee attention
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10 6.
Emergency Preparedenss 6.
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14 10.
Safety Review Committe 10.
Safety Review Committee
43 35 unschedules trips 34 unscheduled shutdowns
44 9 of which 7 of which
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is considered indication is considered an indication
13 (HPCI) System's steam (HPCI) system's steam
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training with out further training without further i
4 is strained are strained
30 instrument values instrument valves
20 aggressive pursue aggressively pursue
23 five protective practices fire protective practices
48 did not committ did not commit
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6 07/28/80 Personnel Automatic delete j
scram-IRM's ranged down l
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29 Manual Scram Manual-controlled shutdown
9 Personnel Equipment l
CONTENTS Page 1.
SALP Board Chairman Letter to Licensee.................... 111 2.
Licensee Comments
..........................................vii I.
Introduction............................................... 1 II.
Criteria.................................................. 2 III. Summary of Results........................................
IV.
Performance Analyses...................................... 4 V.
Supporting Data and Summaries............................. 25 A.
Noncompliance Data.................................. 25 B.
Licensee Report Data.................................. 26 C.
Inspection Activities.................................
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Investigation and A11egations.........................
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Escalated Enforcement Action..........................
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Management Conferences................................
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Significant Licensee Activities.......................
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Unplanned Reactor Trips...............................
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... No. 50-10 Jocket No. 50-237 Docket No. 50-249 Commonwealth Edison Company ATTN:
Mr. Cordell Reed Vice President Post Office Box 767 Chicago, IL '60690 Gentlemen:
This is to confirm the conversation between you and Mr. R. C. Knop of the Region III staff scheduling June 2, 1982 at 1:00 p.m. as the date and time to discuss the Systematic Assessment of Licensee Performance (SALP) for the Dresden Nuclear Station. This meeting is to be held at the Region III offices, Glen Ellyn, Illinois.
Mr. J. G. Keppler, Regional Administrator, and members of the NRC staff will present the observations and findings of the SALP Board. Since this meeting is intended to be a forum for the mutual understanding of the issues and findings, you are encouraged to have appropriate representa-tion at the meeting. As a minimum we would suggest you, Mr. D. P. Galle,
'Mr. D. J. Scott and managers for the various functional areas where problems have been identified. Since portions of the report address relationships with the bargining unit it is suggested that consideration be given to having representatives of industrial relations at the meeting.
The enclosed SALP Report which documents the findings of the SALP Board is for your review prior to the meeting. Subsequent to the meeting the SALP Report will be issued by the Regional Administrator.
Enclosure 1 to this letter summarizes the significant findings identified in the SALP Board's evaluation of the Dresden Nuclear Station for the period of July 1, 1980 through December 31, 1981.
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Commonwealth Edison Company
If you desire to make comments concerning our evaluation of your facility, they should be submitted to this office within twenty days of the meeting date; otherwise, it will be assumed that you have no comments.
In accordance with Section 2.790 of the NRC's " Rules of Practice" Part 2, Title 10, Code of Federal Regulations, a copy of this letter, the SALP Report and your comments, if any will be placed in the NRC's Public Document Room when the SALP Report is issued.
The comments requested by this letter are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-5111.
If you have any questions concerning the SALP Report we will be happy to discuss them with you.
Sincerely, J. A. Hind, Director Division of Emergency Preparedness and Operational Support Enclosures:
1.
Significant Findings 2.
Dresden Nuclear Station SALP Report (5 copies)
cc w/encls:
Resident Inspector, RIII iv
Enclosure 1 During the July 1980 through December 1981, evaluation period, Unit I re-mained in an extended long term shutdown for modifications. Accordingly, the majority of this report is based upon licensee safety performance in regard to the operation of Units 2 and 3.
The licensee's performance in the various functional areas is skewed toward superior performance (Category 1) and weak performance (Category 3).
Of 11 functional areas evaluated four were rated Category 1, four Category 3, and only three Category 2.
An underlying factor in both the Category 1 and 3 rated functional areas was the degree and effectiveness of management commitment and attention. Where management appeared committed and strongly involved, performance in that area was significantly better.
On the other hand, where management did not appear to be totally committed to resolving significant problems, performance was less than desired.
Two of the more significant problems that surfaced in two or more func-tional areas that reflect an attitude and communication concern were:
the relationship between licensee management and the bargaining unit; and the evaluation of operating events and radiation hazards. Policies and relationships between managecent and bargaining units appear to have an adverse offect on safety performance. The nonconservative approach and lack of indepth and thorough review of significant operating events were aggravated, or due in part, to poor communication and relationships between different parts of the station organization and between the station and corporate review groups.
Functional Areas Plant Operations Although improvements have been noted as the result of NRC-licensee man-agement meetings, the magnitude of NRC attention required in this area in regard to significant items of noncompliance and equipment reliability and operability indicates the need for continued licensee attention. Specific licensee attention is required to minimize personnel errors, improve atten-tion to detail, stabilize the organization, ensure responsibilities are understood, and ensure appropriate level of review of operating events.
Radiological Controls Although the licensee has acknowledged many of the concerns in this area and has effected some improvements, there has been an apparent inability to overcome management weaknesses, expressed in the previous SALP meeting, the H. P. Appraisal and management meetings with the licensee. The licensee needs to devote special attention to this functional area.
Emergency Preparedness Management attention and involvement in this area were very evident and effective The resources devoted resulted in a high 1cvel of performance and the generally on time implementation of the many initiatives.
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Security and Safeguards Although these were guard morale problems, a few minor problems and numerous allegations and investigations into charges of improprieties relating to security, the effectiveness and responsiveness of management and personnel at all organizational levels resulted in a high performance level. The Board is concerned about potential long term effect of the morale problem and encourages the licensee to continue the prompt and effective attention given this matter when it surfaced.
Refueling The high level of performance in the areas of core physics and fuel handling were indicative of licensee's management attention in this area. Problems which occurred during refueling outages, but not specifically related to refueling, are covered in other functional areas.
Licensing Activities Overall performance at licensing meetings and responding to NRC initia-tives and concerns continued at an acceptably high level. Technical competence and management attention to solving licensing problems with the NRC were major licensee strengths.
Safety Review Committee Activities This specific area was highlighted by the Board as a special area needing specific licensed attention. The weaknesses identified in this area were the subject of several management conferences between the licensee and the NRC and are part of the overall problems covered under plant operation and radiological controls.
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Commonwealth Edison One First National Plaza. Chicago. Ilknois Address Reply to: Post Office Box 767 Chicago, Illinois 60690 June 18, 1982
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Mr. James G. Keppler, Regional Administrator Directorate o f Inspection and Enforcement - Region III U.S. Nuclear Regulatory Commission 799 Roosevelt Road Glen Ellyn, il 60137 Subject:
Systematic Assessment o f Licensee Performance (SALP)
Commonwealth Edison Company Comments Dresden Station Units 1, 2, and 3; Quad Cities Station Units 1 and 2; and Zion Station Units 1 and 2 NRC Docket Nos. 50-10/237/249, 50-254/265, and 50-295/304 References (1):
47 FR 12240 dated March 22, 1982.
(2):
J.
A. Hind letter to Cordell Reed dated May 26, 1982 (Dresden Station).
(3):
J.
A.
Hind letter to Cordell Reed dated May 26, 1982 (Quad Cities Station).
(4):
J.
A.
Hind letter to Cordell Reed dated May 26, 1982 (Zion Station).
(5):
Cordell Reed letter to J. dated June 2, 1982.
Dear Mr. Keppler:
The purpose o f this letter is to transmit comments as allowed in Reference (1) in response to the Systematic Assessment o f Licensee Performance (SALP) reports provided in References (2), (3),
and (4).
Specific detailed comments for each of the subject sites were presented at the public meeting o f June 2, 1982.
With respect to Dresden and Zion Stations, the more significant comments made are documented in the enclosures to this letter.
As was indicated in Reference (5), Commonwealth Edison believes that improvements could be made in the SALP process which would further induce improvement in licensee performance and promote regulatory resource conservation.
These improvements relate to the apparent lack of definitive assessment standards especially in the case of exceptional performance (Category 1); but also, as relates to the foundation for Category 3 performance.
It is our view that pp~
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problems, an objective we believe is fully met.
However, this audit process may not be capable of evaluating fully the positive aspects of licensee performance.
In as much as the SALP review interval is-relatively short, the fortuitious occurrence of a number of plant-performance deviations can give an inaccurate perspective of true-performance.
For these reasons, we ask only that in completing your.
review, appropriate consideration of positive performance trends-
both prior and subsequent to the SALP interval be considered - just-as potential negative trends have already been considered.
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We are available at your convenience to discuss these comments.
Should you have any questions, please direct them to this o f fice.
Very truly yours, f'
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I Cordell Reed Vice President Enclosures i
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Enclosure 2 SALP Review July 1, 1980 to December 31, 1982 Dresoen Station We have reviewed the issues and findings from your SALP Evaluation of Dresden Station operation during the July,1980 -
December, 1981 evaluation period which were forwarded to us in Reference (2).
Our review indicates that one section o f the supporting data which was used as the basis of one of the board's conclusions is incorrect.
Further, we feel that several of the other conclusions reached in the evaluation are not supported by the underlying data, and that the conclusions regarding the lack of in-depth and thorough reviews of significant operating events by the safety review commiteee is not warranted.
Most importantly, we believe that the station managment was acting in a responsible fashion to conduct a thorough analysis to properly interpret the significance of several of the events which are mentioned in the report without taking precipitous action in declaring systems important to the safe operation of the station inoperable and removing them from service.
Section V-H of the report, entitled " Supporting Data and Summaries of Unplanned Reactor Trips" is in error.
The reactor trip on July 28, 1980, was not inadvertently caused by personnel, but was a planned trip taken to satisfy tne requirements of IE Bulletin 80-17 to investigate the possible accumulation of water in the scram discharge volume headers.
The unplanned reactor trip listed on June 30, 1981, was in f act not a trip, but was a controlled shutdown of the unit af ter one of the recirculation pumps had been tripped.
Finally, the reactor trip on Unit 3 on August 30, 1980, was also not inadvertently caused by personnel, but was the result of equipment failures in the feedwater heater system.
We have discussed these corrections with the Senior Resident Inspector at Dresden Station, and hc concurs with them.
We disagree with the board's conclusions in the summary LER evaluation in Section V-B.
During the SALP 1.,
13.2 percent of the LERs which were submitted were due to personnel error whereas during the SALP 2.
evaluation period 16 percent were due to personnel error.
We believe this percentage difference is statistically negligible and does not support the conclusion that it indicates a casual appoach to some employes to their jobs, resulting from interactions between the bargaining unit and management. We continue
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to be very concerned with personnel errors which result in events which must be reported to the NRC, and we review those events thoroughly in an effort to improve our operations and to reduce the (
probability of a recurrence of those events.
However, we believe i
that the 2.8 percent increase is not statistically significant and l
does not support the categorization that it is the result of a casual approach of some employees to their jobs.
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-2-We also disagree with conclusions regarding plant operations in Section IV.1.
As mentioned above, the number of unscheduled reactor trips caused by personnel error which was used to form conclusions in that section is incorrect. Furthermore, the interviews of individuals involved in a single reactor trip on December 4, 1980, are insufficient to support the categorical conclusion of a fundamental inadequacy in the management of day-to-day operations at the station.
Most importantly, no safety limits or limiting conditions of operation were violated during the startup and scram on December 4, 1980.
With respect to the changes of responsible personnel which were occurring during the startup, we concede that these changes added unnecessary confusion which contributed to the unit trip.
However, we do not concur that this single event can be cited to support the conclusion of a fundamental inadequacy of the management of day-to-day operations at the station.
In 1980, Dresden Unit 2 led the world in availability among BWRs.
In 1981, Unit 3 at Dresden was the leader in this category in the United States.
Neither of these records could have been attained without strong day-to-day management of operations at the station.
We believe the rating of below average in-plant operations is unjustified and incorrect.
Finally, we do not agree that excessive time is required by the safety review committee to recognize conditions which would involve Technical Specification action statements.
Several of the events which were cited to support the conclusion were extremely complicated, sporadic in nature, or involved perviously observed phenomena, and a prompt conclusion to remove a system imf.Jrtant to the safety of the unit from service was not easily justifiable.
The investigation into the failure of the diesel generator cooling water pump check valves was hampered by its sporadic occurrence and a lack of installed instrumentation to indicate adequate flow actually occurring through the pump.
The inadvertent repressurization of Unit 3 involved phenomena which had never before been observed.
An extensitve evaluation by the Nuclear Safety Analysis Center was conducted before the event was thoroughly understood.
The accumulation of water in the HPCI steam line was also not readily apparent justification for declaring the HPCI system inoperable, and thereby positively removing a system important to the safe operation of the plant from service.
Subsequent analyses showed that the accumulated water would have had a minimal effect on the HPCI steam piping.
Further, since the accumulation apparently existed for a considerable length of time, there were repeated surveillances during that period to indicate that the HPCI system would continue to perform as required by Technical Specifications until a detailed review could be made on a modification initiated to drain the water from the line.
We believe the time required by the safety review committee to evaluate the importance of several of these events represented an ef fort, in fact, to conduct a thorough analysis so that the true significance of the events could be understood and the root causal factors responsible for them could be olagnosed.
Thus, X
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t we continue to believe that the station management is acting responsibly to understand the events which have occurred at the station, while not percipitously removing important safety systems from service.
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I.
INTRODUCTION The NRC has established a program for Systematic Assessment of Licensee Performance (SALP). The SALP is an integrated NRC Staff effort to collect available observations and data on a periodic basis and evaluate licensee performance based upon these observations. SALP is supplemental to normal regulatory processes used to insure compliance to the rules and-regulations. SALP is intended from a historical point to be sufficiently diagnostic to provide a rational basis:
(1) for allocating future NRC regulatory resources, and (2) to provide meaningful guidance to licensee management to promote quality and safety of plant construction and operation.
A NRC SALP Board composed of managers and inspectors who are knowledge-able of the licensee activities, met on April 5,1982, to review the collection of performance observations and data to assess the licensee performance in selected functional areas.
This SALP Report is the Board's assessment of the licensee safety performance at the Dresden Station during the period of July 1, 1980 through December 31, 1981. During this period Unit I remained in a long term shutdown for modifications. Accordingly, inspection activi-ties on that unit were limited to the areas of radiological protection and controls, security, environmental protection, and the maintenance of adequate conditions during a long term shutdown. This report, then, focuses upon Units 2 and 3 in most fur.ctional area evaluations.
The results of the SALP Board assessments in the selected functional areas were presented to the licensee at a meeting held June 2, 1982.
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II.
CRITERIA The licensee performance is assessed in selected functional' areas depending whether the facility is in a construction, pre-operational or operating phase. Each functional area normally represents areas significant to nuclear safety and the environment, and are normal programmatic areas. Some functional areas may not be assessed because of little or no licensee activities or lack of meaningful observations.
Special areas may be added to highlight significant observation.
One or more of the following evaluation criteria were used to assess each functional area.
1.
Management involvement in assuring quality 2.
Approach to resolution of technical issues from safety standpoint 3.
Responsiveness to NRC initiatives 4.
Enforcement history 5.
Reporting and analysis of reportable events 6.
Staffing (including management)
7.
Training effectiveness and qualification.
However, the SALP Board is not limited to these criteria and others may have been used where appropriate.
Based upon the SALP Board assessment each functional area evaluated is classified into one of three performance categories. The definition of these performance categories is:
Category 1.
Reduced NRC attention may be appropriate. Licensee management attention and involvement are aggressive and oriented toward nuclear safety; licensee resources are ample and effectively used such that a high level of performance with respect to operational safety or construction is being achieved.
Category 2.
NRC attention should be maintained at normal levels.
Licensee management attention and involvement are evident and are concerned with nuclear safety; licensee resources are adequate and are reasonably effective such that satisfactory performance with respect to operational safety or construction is being achieved.
Category 3.
Both NRC and licensee attention should be increased.
Licensee management attention or involvement is acceptable and considers nuclear safety, but weaknesses are evident; licensee resources appear to be strained or not effectively used such that minimally satisfactory performance with respect to operational safety or construction is being achieved.
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l III. SUMMARY OF RESULTS Functional Area Assessment Category 1 Category 2 Category 3 1.
Plant Operations X
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Radiological Controls X
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Maintenance X
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Surveillance and Inservice Testing X
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Fire Protection and
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Housekeeping X
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Emergency Preparedenss X
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Security and Safeguards X
8.
Refueling Activities X
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Licensing Activities X
i 10. Safety Review Committe
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Activities X
11. Environmental Controls X
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IV.
PERFORMANCE ANALYSIS 1.
Plant Operations a.
, Analysis All or large portions of 21 inspections and one investigation of plant operations were conducted by the resident inspectors and regional personnel. As a result nine items of noncompli-ance and one deviation were identified. Additionally, seven Confirmation of Action Letters (IAL or CAL) were issued in relation to the operation of Units 2 and 3.
Section V of this report " Supporting Data and Summaries" provides additional information concerning noncompliances, CAL's, management meetings, and other statistical data.
Enforcement History TWo of the identified noncompliances that occurred during the first third of the evaluation period are of particular significance:
(1) The Severity Level IV noncompliance contained in Inspection Report No. 50-237/80-16 which addresses the matter of two operators observed to be sleeping or inattentive to their daties, and which resulted in an $18,000 civil penalty, and (2) the Severity Level III noncompliance contained in Inspection Report No. 50-249/80-29 which addresses the inadvertent repres-surization of Unit 3 from cold shutdown to approximately 275 psig without primary containment integrity, and which progressed for approximately six hours without being detected by control room personnel. The inattentive operator issue attracted intense media and public interest. The repressur-ization event resulted in Region III issuing a Confirmation of Action Letter (CAL) requiring licensee corrective action prior to continued operation of Units 2 and 3.
A Severity Level VI noncompliance was issued as a result of the licensee's failure to promptly notify the NRC of the repressurization event.
The six remaining items of noncompliance involved: Failure to follow procedures:
(1) Severity Level IV noncompliance for instrument valves in wrong position, (2) Severity Level V for inadequate jumper and lifted lead log entries, (3) Severity Level V for high torus level, (4) Severity Level VI for failure to adjust the initial pressure regulator during startup, and (5) a deficiency and a repeat Severity Level V item for failure of operators to complete required reading.
Unscheduled Reactor Trips Units 2 and 3 experienced 35 unscheduled trips from power conditions, 9 of which rare due to personnel error. The balance were a result of equipment failure, procedure
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J inadequacies, or other causes. The number of trips resulting from personnel error is considered indication of weakness in the areas of communications and attention to detail among station personnel.
During December of 1980 the Unit 2 reactor experienced six trips in a seven day period (3 of these are not described in Section V.H because of plant conditions at the time they occurred). Following the December 4, 1980 trip on low condenser vacuum an indepth interview of individuals in-volved was conducted by a regional inspector with licensee management.
During the interview it was determined that:
1.
The rate at which activities were being accomplished (clearing outages, training of operator candidates, unit startup, changes of responsible personnel) resulted in confusion, which in turn resulted in the unanticipated, unstable conditions resulting in the trip.
2.
Prior to unit startup no attempt was made to document equipment conditions in comparison to the startup pro-cedures, so that the startup procedures could not be used to guide activities.
3.
Each individual involved in activities knew how to accomplish his job, however, there is no evidence that the effort was managed.
4.
Disagreements betwnen supervisory and bargaining unit employees over the relief dinner policy" caused re-sponsible personnel changes during critical evolutions, and further confused the issue.
5.
The individuals accomplishing various tasks did not communicate with the individual responsible for overall plant status, because no individual was performing this responsibility.
This event is considered indicative of a fundamental in-
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adequacy in the management of day to day operations at the
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station, which often leads to undesirable conditions.
In addition to the enforcement actions and events described above several additional events described in other portions of this report reflect upon the lack of interface between the operating organization and other support organizations.
Concerns surfaced in regard to the adequacy of intercom-munications between individuals and organizations during the investigation into the cause of the 22 rem overexposure (Paragraph 2), and in maintenance noncompliances including i
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the Severity Level IV for instrument valves in the wrong position, and the two Severity Level V citations for inadequate control of valve positions during maintenance to CRD Hydraulic Control Units and feedwater pump maintenance (Paragraph 3).
Management Conferences A total of five management meetings and enforcement con-ferences were held with the licensee in addition to numerous conference calls in regard to enforcement issues described above and problems over the resolution of equipment failures which affected plant operations. Equipment failures of par-ticular concern include water accumulatiou in the Units 2 and 3 High Pressure Coolant Injection (HPCI) system's, steam piping, piping support damage in Containment Cooling Service Water (CCSW) systems, and inoperability of the Diesel Generator Cooling Water Pumps for Units 2 and 3.
Support from licensee corporate functions responsible for assisting operating stations in solving technical and safety problems appeared to be lacking. This was especially true in the case of events which require indepth technical analysis of causual factors and safety implications to fully diagnose the need for remedial action, and potential advarse effects on public health and safety. This observation is based upon the lack of involvement by corporate engineer.'.ng and other review groups in the assessment of events suen as water collection in the HPCI steam supply lines, the inoperability of the Diesel Generator Cooling Water Pumps, the piping support damage to the CCSW System, and operability problems with the Scram Discharge Volume Level Monitoring System.
A management meeting was held on December 23, 1981, in an effort to resolve major issues concerning equipment failure and inoperability. The adequacy of station and corporate management organization's efforts to communicate and analyze safety concerns in regard to day to day station operation were discussed. The need to effectively assess the circumstances and casual factors associated with events which occur at the station was also discussed. Regional management also questioned the effectiveness of the corporate nuclear safety and event review functions because their involvement is not obvious during many significant events.
Preliminary indications are that licensee responsiveness to NRC concerns in this area is positive, and that communica-tions and planning are improving in regard to day to day activities of the station staff.
Sufficient time has not passed since the meeting to determine whether or not long term improvement has occured in this area.
To improve shift coordination and communications the licensee has implemented a shift team manning concept with the bargaining unit (same people on a shift working together as a team). The regional staff agrees that this concept should enhance the-quality of shift operations.
NRC concerns were expressed that the short tenure of individuals in key station staff positions appears to be a contributing factor to operational inadequacies which have been observed.
b.
Conclusion The licensee is rated Category 3 in this area.
c.
Board Recommendations l
The enforcement history and magnitude of NRC attention in this area indicates that increased licensee effort is required to
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i improve operational performance.
Specific attention is required
to minimize personnel. errors, improve attention to detail, stablize the organization, assure that responsibilities are understood, and assure appropriate level of review of operating events.
The current increased level of NRC attention should be maintained to assure that the licensee's corrective action is effective.
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Radiological Controls
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Analysis Radiation Protection and Waste Management i
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Six inspections (two refueling, two to review corrective actions in response to the Health Physics Appraisal, and two
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special inspections of personnel overexposures) were performed during the evaluation period by region based inspectors. The resident inspectors also inspected in this area. Nine items of noncompliance were identified.
Four of the noncompliances (two Severity Level II and two Severity Level III) addressed failures to perform adequate surveys and evaluations of radiation hazards and resultant personal overexposures of 22 rems and slightly greater than 3 rems. A civil penalty of $80,000 was imposed for these events.
In addition to the enforcement conference related to the civil penalty, a separate enforcement conference was held on January 20, 1982, to discuss an unplanned personal exposure incident in December 1981 which resulted in two noncompliances: Failure to perform adequate surveys and evaluations of radiation hazards (Severity Level IV) and failure to control access to a high
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radiation area (Severity Level IV). Although this incident did not result in a personal overexposure, it demonstrated significant programmatic shortcomings in the radiation protection program.
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.The three remaining items of noncompliance concerned failures to follow procedures (two Severity Level V noncompliances) and in-adequate packaging of a radioactive waste shipment (Severity Level V).
The Health Physics Appraisal, conducted partially in this evaluation period, identified seven significant programmatic weaknesses and three additional noncompliances.
Because the Health Physics Appraisal findings were incorporated in SALP 1, they are not included in this summary.
A serious problem evidenced by the licensee's marginal radiation protection performance during this evaluation period is the re-current failure of radiation protection personnel to adequately evaluate potential radiation hazards. This problem appears indicative of weaknesses in training and attitude of radiation protection personnel and management of the radiation protection program.
Licensee management appears cooperative but has not been effective in preventing these recurrent personnel errors in evaluating radiation hazards.
Management weaknesses appear to result from CECO policy rather than personal shortcomings of the plant health physics manage-ment staff. This observation is based on the following noted weaknesses in the radiatien protection program.
(1) Valuable management tools necessary to shape an effective radiation protection program are not available to plant management as evidenced by the existence of plant radiation protection standards which must be negotiated with the union, and a radiation protection qualification program that promotes radiation protection personnel to full technican status immediately upon completion of their training with out-further incentives to promote quality of work (2) The radiation protec-tion organization combines radiation protection and chemistry functions at the technical level. Numerous detailed tasks must be performed by the technicians, many after prolonge'd absences due to job rotation. The spectrum of skills required to perform these tasks appears too great to allow development and maintenance of effective competence in all tasks.
(3) The radiation pro-tection organization lacks sufficient direct supervision by
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i health physics professionals. This places an inordinate burden
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on the Chemistry and Radiation Protection Supervisor, impedes information flow between the professional health physi,fsts and the technicians, and deprives the technicians of needed technical
expertise and supervision.
These weaknesses in the radiation protection programs reflect j
CECO policies regarding organization and conduct of their j
radiation protection programs.
i Similar problems were identified and communicated to the licensee during the Health Physics Appraisal.
In response to the Health Physics Appraisal, the licensee initiated programs to strengthen
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organization and management, training / retraining, contamination l
control, ALARA, emergency monitoring and sampling, access
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controls, surveillance, and instrumentation.
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Some improvements in these areas have been made, however, the
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underlying managerial problems have not been resolved. Without s
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significant changes in the interfaces between labor and, man-agement, it is questionable whether the plant can effect truly
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significant improvements in the_ radiation protection program.
No'significant problems were identified in the radioactive waste program during this evaluation period. Liquid radioactive re-
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leases were significantly lower than average when normalized for.
l power-(Ci/MWe); gaseous radioactive releases were higher than j
average in total curies but average when normalized for power
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(Ci/MWe). -Both liquid and gaseous releases were well within Technical Specification Limits. -:One unplanned release occurred, neither the release quantity nor concentration exceeded regula-
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tory limits. Other than the one item of noncompliance, no-significant problems were identified with the radwaste
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i transportation program during this evaluation period.
b.
Conclusion
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The licensee is rated Category 3 in this area. This is based on
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the poor radiation protection enforcement history _which included two Severity Level II violations, two Severity Level III viola-tions, andLtwo Severity Level IV violations during this evaluation period, and management's inability to-effect appro-priate corrective actions. This is the second consecutive SALP period in which the licensee has been rated low in this area.
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Board Recommendations
NRC inspection' efforts of radiation protection activities should be increased. No other changes in the inspection program are needed. The board recommends that the licensee place more emphasis on providing health physics professional input into
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l direct supervision of the Radiation Protection organization.
The board further recommends that the licensee pursue changes i
or modifications to its policies to alleviate weaknesses in their program that are perceived to be a product of management
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and bargaining unit labor practices.
3.
Maintenance a.
Analysis Station maintenance activities were inspected during portions of seventeen routine inspections and two reactive inspections resulting from maintenance related problems. Portions of three inspections addressed design changes and modifications. Three items of noncompliance with NRC requirements were identified:
(1) Unit 2 High Pressure Coolant Injection System (HPCI)
rendered inoperable as a result of improper assembly of the Turbine Steam Supply Valve (2-2301-3) (failure to have a procedure for work), Severity Level IV.
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(2) Failure to adequately control valve positions during feedwater pump outage, Severity Level V.
(3) Failure to adequately control valve positions during outage on two Control Rod Drive Hydraulic Control Units, which is a repeat of Item (2), Severity Level V.
The low number of noncompliances and Licensee Event Reports (LER's) resulting from maintenance activities is indicative of satisfactory licensee performance in this area. Observa-tions by many individuals inspecting activities of the station, however, indicated that individuals performing maintenance activitics often did not adequately clean up and return areas and equipment to a satisfactory condition with respect to housekeeping requirements.
Further concerns focused upon the capability of the overall corporate and station organizations to adequately analyze, resolve, and take timely and effective corrective action in response to equipment malfunctions which involve casual factors other than normally expected wear and use.
For example:
(1) Following the noncompliance for improper assembly of the HPCI Steam Valve (2-2301-3) it was discovered that Unit 2 HPCI steam piping supports had been damaged, and that water was accumulating in horizontal piping runs to a depth of 30-50% of the pipe diameter. A similar condition of water accumulation in the Unit 3 HPCI steam line was discovered following an NRC concern that the problem may also exist on that unit.
In both events the licensee took a noncon-servative approach, and was reluctant to declare the affected equipment inoperative. Corrective actions appeared to focus more on speaking to concerns than to engineering a safe solution to them. The NRC issued a Confirmatory Action Letter (CAL) to insure that the HPCI equipment was declared inoperable until adequate drains were installed, and test
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programs to demonstrate adequacy of repairs were performed.
Long term corrective actions to address Region III concerns
and observations that piping support damage resulted from inadequate design are still being evaluated as a portion of
'
the design evaluation program required by Inspection and Enforcement Bulletin No. 79-14.
(2) Similar concerns exist surrounding the adequacy of licensee evaluations and investigations into piping support damage which occurred to the Containment Cooling Service Water System (CCSW); and the licensee's actions in regard to repeated maloperations of the Emergency Diesel Generators (2 and 2/3) Cooling Water Pumps. The CCSW concerns resulted
[
in a CAL, and the Diesel Cooling Water Pump issue resulted i
in three CAL's being issued by the NRC. The licensee demonstrated reluctance in responding to these issues, but
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response was adequate following the issuance of the CAL's.
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Inter.im changes were implemented to the operating instruc-
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tions for the CCSW pumps until an evaluation of piping supports.can be completed. The Diesel Generator C olin,
Water Prep operability problem was solved when the pump discaarge check valves were replaced.
~In cont ast to the above observations the station organ-
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izttion responded commendably to operational difficulties
,
.cyhich were experienced when the new Scram Discharge Volume
' Continuous Monitoring Instrumentation was installed in response to IE Bulletin No. 80-17 and the accompanying generic Confirmatory Order which was imposed on all
applicable BWR licensees.
. Events such as those described above require a response beyond the routine paperwork and repair actions by the maintenance staff for adequate corrective action. Delays
- in completing adequaia corrective actions result in the Tqchnical Specifications Limiting Conditions for Operation for equipment out of service being challenged.
In such
<
cases,a licensee has the options of (1) declaring the
equipment inoperable, and of complying with applicable
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,4 Technical Specification action statements, or (2)
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, developing the organizational capability to analyze and
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correct tne problem to eliminate or reduce forced outages
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resulting from the Technical Specification action state-
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'ments (it is recognized that this cannot always be the case.)
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Current Region III concerns are that licensee actions ara l
often nonconservative in that the root causes of a problem
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are often being overlooked, resulting in equipment being returned to service before it is capable of the service
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reliability implied by the design bases for safety related
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equipment. This apparent failure of upper levels of the
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licensee organization to identify such conditions in a timely manner, and to dedicate necessary resources from the organization to resolve the problems, is further discussed in Section 10 of this report " Safety Review Activities."
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Design Changes and Modifications
Inspections of modifications to the Pressure Suppression Jool
(tor ts) and a design change to install the Scram Discharge j
Voluae (SDV) Continuous Monitoring Instrumentation and other
~(SDV) changes required by IE Bulletin No. 80-17 were condueed.
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. A review of equipment installations, records, record controls, personnel qualifications, and training in regard to these efforts indicate that licensee activities were adequate.
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Observations indicate that management, staff, and contractor l
personnel were attentive to the safety and quality requirements applicable to this work.
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t General
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The station organizations and management responsible for the implementation of numerous post-THI and other NRC safety in-itiatives is strained by the large quantity of work, and by the short schedule for completing the work.
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The overall effectiveness of the station maintenance staff in implementing the routine maintenance and praventative maintenance program is considered adequate.
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b.
Conclusion
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k The licensee is rated Category 2 in this area.
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c.
Board Recommendations
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The Board recommends that the licensee address the concern
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that maintenance activities often lack adequate housekeeping.
Evaluations of licensee performance in this area by inspectors
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and regional management should focus upon observed licensee weakness in identifying problems which require the involvement
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of engineering, design, or external sources of expertise for
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adequate resolution.
Inspection frequency should be maintained at current levels.
4.
Surveillance and Inservice Testing
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a.
Analysis
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Three inspections of Surveillance and Inservice Inspection (ISI) programs were conducted in addition to portions of eighteen resident inspections. Two items of noncompliance
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with NRC requirements were identified, (1) procedures had not been revised to reflect the operability criteria for the evaluation of installed piping suspension components.
l Additionally, procedures contained conflicting require-l ments (Severity Level V), and (2) procedural inadequacies
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resulted in several mispositioned instrument values (Severity Level IV).
In addition to those items, Paragraph 5 of
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this section " Fire Protection and Housekeeping" describes j
noncompliances in which surveillance requirements for
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control room smoke detectors were not conducted for about
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l one year (Severity Level IV), and failure to perform
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certain surveillance procedures for fire protection sis.
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A total of 14 LER's were submitted as a result of surveillance (
tests which were late, missed, or inadequate.
In each case the
/f licensee took prompt and effective corrective action and plant
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safety was apparently not degraded. Observations of the sur-
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veillance and ISI program indicate that licensee performance
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varied for different activities.
In the area of core physics
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the responsible staff was assessed as posessing superior
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competence and a well defined view of the scope and safety objective of their work. Procedures were found to be well written, technically adequate, and conservative in regard to safety concerns. Records were found to be complete, well maintained, and readily available.
In cases where corrective actions were required they were both timely and effective.
Licensee activities in the area of ISI were found to be adequate. The need for increased management attention is indicated, however, to ensure that testing results are analyzed against clearly stated acceptance criteria, and to provide for more effective definition of responsibilities for forwarding test results to appropriate individuals for review.
The program for conducting Technical Specification required routine surveillances to demonstrate the operability of safety related equipment appears to be adequate.
b.
Conclusion The licensee is rated Category 2 in this area, c.
Board Recommendations Insuring that routine surveillances are not missed or late is a single area where performance could he improved.
5.
Fire Protection and Housekeeping a.
Analysis One fire protection program inspection was performed by regional specialists in additioe to routine evaluations of fire protection and prevention measures, and site cleanliness, by the resident inspectors. Five violations of regulatory requirements and four unresolved items were reported:
j (1) Measures were not taken to promptly correct licensee identified deficiencies in fire barrier penetration seals (Severity Level V).
(2) Control Room Smoke Detection Instrumentation was taken out of service for modifications for approximately one year without satisfying all Technical Specification Action statement requirements (Severity Level IV).
(3) Surveillance requirements for fire protection water system valves, fire extinguishers, and housekeeping inspections were not properly performed (Severity Level V).
(4) Fire hose hydrostatic test records were not traceable to the hoses in the plant (Severity Level VI).
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(5) Failure to implement Quality Assurance Program require-ment for housekeeping and combustible material and debris control in areas containing equipment which is important to safety (Infraction). This is a repeat of a similar noncompliance during the SALP I period.
Unresolved Items (1) Equipment in the Plant Yard Hose Houses was found to be poorly organized causing the potential for slow emergency response to a fire. The licensee has committed to remedy this situation.
(2) Fire brigade training in fighting live fires was not performed in 1980. The licensee provided a schedule for this training in 1981.
(3) The licensee has not developed fire fighting strategies or preplanning. This item is being reviewed by the responsible NRC headquarters staff organizations.
(4) The licensee does not hold training fire drills for the fire brigade with adequate frequency. This item is being reviewed by the responsible NRC headquarters staff organizations.
Items (2), (3) and (4) above are considered Unresolved Items because of the way in which they were addressed when new rulemaking was resolved for applicability for the station. The Region III staff position is that the licensee should have included these requirements in his program.
It is noted that most licensees have addressed these items in their fire protection programs.
It is
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anticipated that the resolution of these ' ems will include applying the requirements to the station fire protection program.
Observations made during the regional fire protection inspection indicated that a generally lax licensee attitude existed toward a number of fire protection requirements, including surveillance testing. A new station fire marshall had been appointed who apparently was not made fully aware of the importance of many i
fire protection requirements (such as Technical Specification required surveillances). A reinspection of several areas of weakness after this appraisal i
i indicated the increased management attention and improved definition of the duties of the fire marshall have improved performance in this area, although weaknesses were still found in regard to surveillance and preoperational test documentation.
Concerns of poor housekeeping practices had been an ongoing issue at the station. The licensee implemented
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a new program for performing inspections for housekeeping and reducing identified fire hazards. Observations made to date indicate that licensee performance in this area has improved greatly since the new program has been implemented.
b.
Conclusion The licensee is rated Category 3 in this arca. This rating is based upon performance in the fire protection area.
c.
Board Recommendations The Board notes that the Category 3 rating is resultant primarily from performance in the fire protection area.
Improvements in the area of housekeeping would have resulted in a Category 2 rating in this area, although some concerns exist in relation to the Severity Level IV noncompliance for lack of cicanliness and fire hazards in the Emergency Diesel Generator rooms after the appraisal period. Continued improvement in the areas of weakness identified above should result in a Category 2 rating in the next assessment.
The Board recommends that the licensee take action to aggressive pursue fire protection items. The licensee should incorporate the four unresolved items identified above into their fire protection program, since they are consistent with five protective pratices established in the industry.
6.
Analysis Emergency Preparedness activities at the Dresden site were observed ouring the licensee's exercise and assembly drill, and during the Emergency Preparedness Implementation Appraisal.
In addition to the above observed exercise and drill, the licensee conducted several practice exercises and additional drills.
Even though the current Emergency Preparedness requirements of 10 CFR 50 did not become effective until January 1981, the licensee prepared a draft plan for submittal in July 1980 and September 1980. Based on the observations, we find that the licensee management is involved to ensure that Emergency Preparedness is main-tained at a high level of skill. NRC concerns identified during the September 1981 exercise were addressed and actions necessary to resolve these concerns were begun prior to the November appraisal. Most of the significant findings observed at the licensee's previously appraised facilities had been corrected by Dresden management,
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resulting in a substantial reduction of significant findings at Dresden. A large corporate staff is devoted to Emergency Preparedness, with a former Shift Engineer performing station Emergency Preparedness functions and interfacing with the
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corporate staff. The training program appears to be excellent, in that individuals are aware of their respon-sibilities and the means for implementing them. Although the licensee did not meet the July 1, 1981, installation date for the prompt public notification system, a consider-able amount of effort was expended by the licensee such that installation and testing of this system was completed by the required deadline date of February 1, 1982.
b.
Conclusion The licensee is rated Category 1 in this area.
i c.
Board Recommendations Due to the number of requirements that are due to become effective during the next SALP period, a reduction in the inspection of this area is not warranted.
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7.
Security and Safeguards a.
Analysis Four inspections and one investigation were completed by regional based inspectors during the evaluation period.
The resident inspectors also conducted routine observations of security activities. A second investigation was initiated at the end of the evaluation period and is still in progress.
j The first investigation involved allegations made by a guard
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concerning the security progra m; the licensee was found to be in compliance with their approved security plan. TWo minor noncom-pliances wero identified as a result of the inspection effort.
(1) Deficiency for improper screening documentation on certain contractor personnel.
t (2) Severity Level V violation for failure to maintain certain required security records in the computer system.
A concern was ident'ified regarding the apparent low morale of the guard force and its potential affect on security activities.
The concern developed toward the end of the evaluation period and continues. The licensee has taken steps through the guard contractor to address this concern and raise morale, and there-l l
fore, the effectiveness of the onsite guard force. Although
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some improvment was observed, the process continued beyond the j
evaluation period.
A review of the previous SALP evaluation shows an improvement of the implementation of the security plan through the effective use of personnel, the security computer, and equipment systems.
The licensee appears to have a strong and aggressive site man-agement program that is only limited by the legal relationship between the licensee and guard contractor.
Corporate security
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l management is generally strong and their involvement in site activities usually ensures that decisions, planning, and
assignment of duties are properly placed. Corporate security management did, however, fail to provide a procedure or adequate guidance that could be used by the site to implement the reporting requirements of 10 CFR 73.71(c). This lack of policy guidance, could have led to possible reporting deficiencies for several months even though no significant problems were identified.
The licensee's management generally responds to NRC initiatives in a timely manner. The responses are usually viable and generally sound. There are a few security plan changes that have been requested by the NRC that are currently _being resolved.
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The major outstanding safeguards issue is the designation of the entire power block structure as a vital area. This matter is still under Commission consideration.
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During the evaluation period, there was a change in a key corporate security management position. The position was l
promptly filled so that no significant break in management continuity occurred. The staffing and management of the onsite contract guard force is adequate. Significant morale problems were noted in the guard force. As noted before, the licensee, in concert with the contractor management, has undertaken a program to mitigate the known problems.
Shortly before the end of the evaluation period, significant allegations relating to improper security practices, inadequate guard training, and drug and alcohol use by guards and employees,
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and inadequate management control were made by guards and former
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guards. The site security administrator conducted an extensive and aggressive investigation. A widespread NRC investigation j
has continued beyond the end of this evaluation period.
The major Safeguards tasks facing the licensee are the imple-
mentation of the Security Force Training and Qualification Plan, the Safeguards Contingency Plan, improvement of guard morale, implementation of 10 'FR 73.71(c) reporting requirements, and information protection program to comply with 10 CFR 73.21.
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b.
Conclusion The licensee is rated Category 1 in this area.
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l c.
Board Recommendations At this time, no increase or decrease in inspection frequency or effort is warranted. The Board is concerned with the potential
long term effects of the morale problems described in the T
analysis section above, and encourages the licensee to continue the prompt and effective attention given this matter when it surfaced. The Board also notes that the licensee achieved a l
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Category 1 rating in this area in spite of the numerous issues and allegations which affected day to day performance.
8.
Refueling Activities a.
Analysis Portions of two inspections by the resident inspectors were made of Unit 2 refueling activities in addition to one inspection of testing and core physics activities related to the refueling conducted by Region III specialists. The results of the core physics inspection are discussed in Paragraph 4, " Surveillance."
No outstanding issues, violations of regulations or require-ments, or open items resulted from these inspections. Other.
sections of this report address observations and findings resulting from activities which were accomplished during the refueling, including maintenance; surveillance testing and inservice inspection.
Observations and data indicate that the licensee's nuclear engineering and core physics staff is well organized and contains a sufficient quantity of well qualified personnel.
The combined effects of management attention and the dedica-tion to safety and quality of the staff results in an effective effort which fulfills nuclear safety requirements.
The mechanical evolutions required for refueling are also accomplished in a safe and efficient manner with emphasis upon quality.
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i b.
Conclusion The licensee is rated performance Category 1 in this
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functional area.
c.
Board Recommendations None.
9.
Licensing Activities a.
Analysis The licensee usually provided licensing submittals which were complete, technically adequate, and timely. There was indica-tion of increasing difficulty in meeting large numbers of short turn around requests by the staff. When response submittals were past the NRC deadline proper advance notification was provided and new schedules were proposed.
The combination of extensive experience in dealing with the NRC and the practice of rotating personnel between operations, licensing, and corporate staff positions has resulted in a
licensing staff with a strong working knowledge of NRC regulations, guides, standards, and generic issues. The licensing staff has been responsive to formal and informal NRC requests. Station and corporate management exhibited a good understanding of regulatory requirements and appeared committed to work effectively with the NRC staff. The licensee did not anticipate NRC requirements. They generally waited until the staff reached its final position before responding to requests.
Seven operator and senior operator license examinations were given. Six of the applicants passed the initial examination and the seventh individual passed the re-examination. This level of performance is above that found at other op rating sites.
Overall performance at meetings and in responding to NRC initiatives and concerns continued at an acceptably high level of performance. Technical competance and management attention to solving problems with NRC were major licensee strengths. No i
significant weaknesses were observed.
l b.
Conclusion The licensee is rated Category 1 is this functional area, c.
Board Recommendations It is noted that 4 of 4 individuals failed to pass their license exams following the appraisal period (1 R0, 1 R0 to SRO upgrade, and 2 STA candidates who were unlicensed and sat for the SRO exam). Although this number of results is too small to be of statistical significance, the Board points out two observations which should be considered by licensee management:
(1) The examination results were not adequate in the area of radiological controls. The facility overall performance in this area is Category 3.
Consideration should be given to increased emphasis to training in this area.
(2) A national trend has been observed in regard to STA licensing. Specifically, SRO exam results have been poor.
Licensee management should consider remedial action to reverse this trend for its facilities.
10.
Safety Review Committee Activities a.
Analysis An evaluation of safety review committee activities has been added to this report to emphasize certain observations by individuals involved in inspections and event followup.
It is not a standard functional area for SALP Reports.
It appears that the inadequacies in the performance of safety reviews which
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are described below were a contributing factor to unacceptable licensee safety performance in regard to several issues, including, but not limited to:
(1) The personnel overexposure events described in Section III.2. " Radiological Controls."
(2) The inadvertant repressurization event described in Section III.1. " Plant Operations."
(3) The Diesel Generator Cooling Water Pump operability problems discussed in Sections IV.1. " Plant Operations; IV.2. " Maintenance", and V.C., " Licensee Report Data."
Personnel Overexposure From a strict regulatory enforcement point of view the 22 rem overexposure of a worker during feedwater sparger work was considered failure to conduct an adequate survey (and failure to prevent the overexposure). However, other concerns of licensee performance surfaced as a result of the investigation into the incident. These concerns regard the safety review function.
(1) Workers performing in-vessel work on this job were shielded by two types of shielding; the vendor designed shield plug and the water in the reactor vessel. The shield plug design included a float actuated level alarm to warn its user of an unacceptable decrease in reactor vessel level. This design provision was not utilized.
Had it been utilized the low water level condition (i.e.,
loss of shielding) which was present during the shield plug removal may have been detected. This contributing factor, in addition to the inadequate instrumentation described in Items 2. and 3. below, were not recognized by reviews of the safety aspects of the work.
(2) During outages since initial unit startup a standpipe was installed to provide an additional source of reactor vessel level indication. This practice was stopped in favor of
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using a combination of installed level sensing lines, with or without specially calibrated level transmitters. The level sensing equipment used was not accurate, probably
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because of activities described in 3. below. Neither safety review activities at the time the decision was made to change the level indications available during outages, nor ongoing planning and work coordination meetings during the sparger work anticipated the lack of adequate indications.
(3) The single set of the redundant level sensing lines which was supplying level indication at the time of the event was itself undergoing modifications during the time that it was
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used to determine' adequate level, that is, shielding. This condition was not diagnosed by work planning and review
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activities, i,
Inadvertant Repressurization In addition'to the enforcement action taken for failure of personnel to monitor plant conditions, concerns regarding the adequacy of the technical evaluation of certain plant character-istics and conditions were surfaced during the investigations into the event and the management meeting held to discuss the
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event.
(1) From the time of initial plant operation until just prior
to the event the procedures for station cooldown included i
steps to flood the upper portions of the reactor vessel.
- This flooding resulted in the removal of heat from the upper pressure vessel metal.
Prior to the event the
l cooldown procedures were changed to delete the flood-up
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requirement. The change was to reduce the potential for vessel nozzle thermal stresses associated with a vessel flood-up.
In approving and implementing the revised
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procedure the licensee did not consider potential adverse
effects of the procedure change (i.e., the potential for
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reheating of the vessel water, and the potential for loss
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of vessel recirculation using shutdown cooling pumps for
the motive force).
t (2) The evaluation and review of procedures for the operation of the Shutdown Cooling System did not adequately account for the design of the equipment in that (a) the tempera-
ture indication relied upon in the procedure was not capable of measuring true reactor water temperature with
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the equipment configuration that the unit was in, and (b)
the procedures did not provide for a condition of insuf-
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ficient induced vessel flow to remove decay heat from inside of the core shroud, and (c) the individuals involved in planning 'and reviewing the sequence of operations
l followed did not consider the combined effects of changes to the vessel cooldown procedures, the effects of water
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level vs. Shutdown Cooling System operation with the Recirculation Pumps stopped, and the inaccuracy of the
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j temperature transmitters located in the Recirculation System during low or no flow conditions.
Diesel Generator Cooling Water Pumps At the time when occasional, unexplained problems surfaced with
the pumps the licensee took immediate steps to determine the
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cause. However, since the problem was sporadic in nature, the
licensee took nonconservative actions in that (1) if the pump
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passed a single surveillance test it was considered operable despite the unexplained maloperations, and (2) station manage-ment and onsite review groups did not committ sufficient
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attention, resources, or significance to the problem to assess the safety significance and declare the equipment inoperable and isolate and repair the cause of the malfunctions.
Con-siderable pressure from Region III was required to induce the licensee to invoke the appropriate Technical Specification limiting conditions for operation and action statements.
Corporate engineering, safety, and event review groups did not become involved until such involvement was requested by the NRC.
The problem was resolved after five to six weeks when it was discovered that the pump discharge check valves were broken.
In addition to the above, the original licensee explanations of the causal factors for the malfunctions were (1) foreign object intrusion disabling both the 2 and 2/3 pumps because of a special maintenance suction lineup which made both pumps reliant upon the same water source; a potential common made failure which escaped detection by planning, management, and review functions, and (2)
that the pumps were tripping on overcurrent and automatically restarting without operator actions; this scenerlo is not possible since the pump motor controllers required manual over-current trip resets and event reviewers did not reach this conclusion.
Water in HPCI Steam Lines The initial detection of water in the Unit 2 HPCI steam piping was by an observant equipment attendent who noticed that the piping was cooler than it should be.
It was discovered that a steam supply valve was improperly assembled following main-tenance. Later, piping supports and restraints for the piping were found to be severly damaged. The station management and safety review activities did not declare the HPCI inoperable, and a great deal of NRC pressure was required before the licensee did so.
The nature of the problem (water accumulation in horizontal piping runs as a result of improper sloping), and the cause of support and restraint damage was not properly diagnosed until an NRC piping expert went to the station to review the damage and diagnosed the problem. After the problem was recognized on Unit 2, the same condition was discovered on the Unit 3 HPCI steam piping, but only after a check of Unit 3 was requested by the region. The failure of the licensee's station and corperate engineering groups, safety review groups, and management to take conservative corrective action, and to diagnose the problem, are considered indicative of deficiencies
!
in safety performance.
Based upon the above observations and experiences, and other observations of less significance, the NRC has serious concerns of the effectiveness of Safety Review Committee activities.
Excessive time is required to recognize conditions which would involve Technical Specification action statements. Once such conditions are identified the available station and corporate management resources, which appear to be adequate, appear to remain isolated from solving the problem.
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b.
Conclusion
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f The licensee is rated Category 3 in this area.
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c.
Board Recommendations Performance improvement is needed in this area. The licensee should focus attention on utilizing the existing station and
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corporate organizations more effectively. The inspection
program should emphasize evaluation of overall station ar.d corporate staff effectivenses in resolving events. The Board is also concerned with the trend of relying upon the.NRC to interpret the significance of events or to diagnose the root causual factors responsible for events. The primary function
of the inspection program is to audit the effectiveness of the i
licensee organization; the licensee should be reviewing problems and taking necessary actions to ensure operational safety, t
11.
Environmental Controls
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a.
Analysis TWo routine inspections were conducted in the areas of confirma-
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tory measurements and environmental monitoring. One minor item of noncompliance was identified; Deviation for failure to collect certain cooling water samples. Confirmatory measurements inspec-tions were made during both inspections while an environmental inspection was conducted during one.
In addition two special
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inspections were conducted as a result of licensee reported
events. With respect to confirmatory measurements inspections of the licensee's ability to measure radioactivity in effluents, 90 percent of the licensee's measurements are in agreement with NRC measurements, 4 percent in disagreement and 6 in possible agreement. The licensee's measurement was higher than the NRC measurement in the single disagreement identified in the last
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inspection and therefore conservatively in error. This is better
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agreement than is normally obtained from other stations in the region. The laboratory has an adequate staff and a generous
compliment of instrumentation.
The licensee's routine environmental monitoring program is
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established and maintained by the corporate office with much of the actual work being performed by a contractor. This is the
usual licensee practice in Region III. One item of noncompliance
!
due to failure to collect the weekly water samples at three
locations was identified early in the SALP period. The licensee took adequate corrective measures to prevent recurrence of the
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isolated event and there were no further occurrences.
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I The licensee's annual environmental reports are adequate and meet the requirements, but lack the detailed results usually i'
found in the reports provided by other utilities. The Region III staff notes that including more test results and data would improve the overall quality and usefulness of the reports.
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As part of the NRC response to an apparent loss of 300,000-400,000 gallons of water inventory, the NRC made special radiological measurements at and around the site on September 5, 1980. No radioactivity above natural background was identified.
,Furthermore, after much persuasive effort by the NRC, the licensee agreed to monitor several offsite wells for possible ground water contamination until the end of 1981. Ground water contamination was not found.
A second special inspection was conducted on January 4, 1981, in response to the licensee's reported discovery of slightly contaminated snow outside the Unit 2 reactor building. This contamination resulted in concen-trations in melted snow and ice slightly above the unrestricted
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MPC, but below the restricted values, and was found to have been caused by the test of the isolation condensor the night before.
The event had no significant consequences. The licensee tested the isolation condenser water for contamination before the test but the source of contamination was apparently dislodged by the
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boiling of the water during the test. Violation of NRC regulations neither caused nor resulted from the event.
b.
Conclusion The licensee is rated Category 2 in this are'
c.
Board Recommendations
Nc::e.
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V.
SUPPORTING DATA AND SUMMARIES A.
Noncompliance Data Facility Name: Dresden, Units 1, 2, and 3 Docket No. 50-10 Inspections No. 50-10/81-13 through 50-10/81-20 Docket No. 50-237 No. 50-237/81-14 through 50-237/81-37 Docket No. 50-249 No. 50-249/80-18 through 50-249/81-29 Noncompliances and Deviations Functional Severity Levels Categories Area Assessment I II III IV V VI Viol.
Infr.
Def.
Dev.
1.
Plant Operations 1 (1) 2(1) 1 1(2+)
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2.
Radiological Controls
2
(1)
1(1+)
3.
Maintenance
2
,
4.
Surveillance and (1)
Inservice Testing 5.
Fire Protection and (1)
(2)(1)
(1+)
Housekeeping 6.
Security and (1+)
(1+)
Safeguards 8.
Refueling 9.
Licensing Activities
.
10. Safety Review j
Committee Activities i
11. Environmental (1+)
Controls Total 0 2 3 2(3) 5(4)
1(1) 0 1(2+) 1(3+)
(1+)
(1+)
Items marked with a "+" also apply to Unit 1.
- Items in parenthesis () apply to both Units 2 and 3.
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B.
Licensee Report Data LER COMPARISON FOR UNITS 2 AND 3*
Period 1 Period 2 (12 Months)
(18 Months)
Proximate Cause*
7/1/79 through 6/30/80 7/1/80 through 12/31/81 Personnel Error 10(.83)**
27(.94)**
Design, Manufacturing 12(1)
16(.9)
and Construction /
Installation External Cause 0(0)
0(0)
Defective Procedure 3(.25)
7(.4)
Component Failure 49(4)
109(6)
Other O(0)
4(.2)
TOTAL 76(6.3)
162(9)
- Proximate cause is the cause assigned by the licensee according to NUREG-0161, " Instructions for Preparation of Data Entry Sheets for Licensee Event Reports (LER) File."
- Numbers in parenthesis are number of events per month.
NOTE: Unit 1, which remained shutdown for an extended outage for modifications has two reportable events.
Both resulted from personnel errors as a result of failure to sample radioactive waste tanks.
In the SALP 1 period Unit I also reported two events, one of which was a personnel error, the other was a component failure.
Summary LER Evaluation During the SALP 1 period, the station submitted 76 LER's of which 10 or 13.2% were due to personnel error as compared to SALP 2 where 27 LER's of 162 or 16% were due to personnel error. This increase is of significance as it indicates a casual approach of some employees to their jobs, resulting from interactions between the bargaining unit and management. The problem does not appear predominent among any particular group or trade as the LER's show a reasonably uniform distribution over the station work force.
During the SALP 2 period the average number of LER's generated per month increased to 9 from 6.3 in the SALP 1 period. While this increase is considered significant, the region has reviewed the LER data, and has concluded that insufficient data exists to accurately determine a statistical trend because the number of LER's appeared to have increased in a number of different areas.
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It has been suggested that some of the increase in numbers of LER's may be due to an increased awareness of the station staff.
It is suggested that the licensee evaluate LER's to indicate areas where performance improvement is needed.
Several events of particular significance are; on five occasions, instruments or detectors from safety-related functions were found vs1ved out as a result of personnel error.
On two occasions, numerous LPCI heat exchanger tubes were found leaking. However, this was found through increased surveillances resulting from the apparent 300,000 to 400,000 gallon water loss early in the period.
The surveillances were increased to monthly periodicity and no further leakage has been detected on either unit after these events. On two occasions, torus water level was allowed to exceed Technical Speci-fication limits as a result of testing ECCS equipment. This resulted in a citation on the first event and had been the subject of previous citations. The resultant corrective action was a Technical Specifi-cation change allowing a six hour period to take corrective action when the torus level is out of specification.
t On two occasions, the Unit 3 Emergency Diesel Generator and the swing (Units 2/3) emergency diesel generator were out of service simultaneously.
In both cases, the required reactor shut down was started until at least one diesel could be returned to service.
In both cases the diesel generator failure resulted from equipment failure. The events are considered significant because of the potential adverse consequences of having both emergency diesel generators serving a unit inoperable simultaneously. Subsequent corrective action was adequate.
On one occasion, the HPCI steam line on Unit 2 was found with a water build up that was the result of improper steam supply valve reassembly following maintenance, which prevented normal drainage of the steam line. The event resulted in a citation.
On one occasion, when the Unit 3 reactor was in cold shut down with the primary containment disestablished, the reactor was
allowed to heat up and repressurize in excess of 90 psig. This resulted in a Severity Level III citation. No civil penalty was issued because of the initial conditions (shutdown) of the reactor at the time the event began. The final significant item was a scram of Unit 3 caused by a high trip of the Intermediate Range Power Monitors which resulted from the power increase caused by an unplanned double notch withdrawal of a single control rod. The event is unusual in that it did not occur from an initial control rod position of fully inserted while operating pressure to the control rod drive was elevated, which normally preceded such events in the past.
C.
Inspection Activities The most significant inspection activity was the ongoing inspec-tion effort conducted by the two resident inspectors assigned to the site. The resident inspections were augmented by support from regional based specialists who assisted in seven inspections.
Additionally, twenty three inspections were conducted by regional inspectors. These inspections addressed routine inspection program activities including emergency preparedness, an appraisal of the licensee's radiation and environmental protection programs, radiation protection inspections, and the licensee security and safeguards program; and reactive inspections in response to licensee events.
D.
Investigations and Allegations 1.
Numerous allegations of improper conduct of contractor security guards at Dresden and other licensee stations, and of improper security guard qualifications were received. The allegations have resulted in several investigations by regional security specialists and investigators which are still continuing at this time. The results of ona inves-tigation of guard training and qualification were forwarded to the Department of Justice for evaluation of the necessity for further investigation for criminality. Further action was declined by the Department of Justice based upon the promptness and effectiveness of management corrective actions following the discovery of the problems.
2.
An investigation was conducted into the circumstances sur-rounding the overexposure of a co.. tractor employee to approximately 22 rems of whole body radiation while working in the Unit 2 reactor vessel. The investigation and other inspections into this event resulted in a civil penalty which is discussed in Paragraph IV.2 of this report " Radiological Controls."
3.
An investigation into allegations made to the news media that the licensee was attempting to withhold information or to cover up information in regard to the matter of two licensed control
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i room operators who were alleged to have been sleeping or inat-tentive to duties while responsible for unit operations resulted in a civil peanity of $18,000.00 and's Severity Level IV noncompliance for operator inattentiveness which is documented in Investigation Report No. 50-237/80-16 and dis-cussed in Paragraph IV.1 of this report " Plant Operations."
4.
Allegations were made to the news media by an unidentified individual who identified himself as a station employee that 300,000 to 400,000 gallons of water contaminated with low level radioisotopes had been released to the environment without licensee controls, and that the licensee was with-holding notification of this event from the NRC. The allegations were followed up by special inspections which concluded that the allegations were unfounded.
5.
A former licensee employee alleged that the Commonwealth Edison Company's operation of the Dresden, Quad-Cities and Zion stations creates a substantial safety hazard and therefore is reportable per 10 CFR Part 21.
The allegation was based on the conclusion that licensee management was promulgating operating directives and philosophies which were unsafe in that they authorized departure from the Technical Specifications and that the licensee's corrective action's were incomplete or ineffective. These allegations resulted in an extensive evaluation of the plant events, corrective action, and corporate management policies and procedures specifically addressed by the alleger. The special inspection conducted relative to this matter determined that none of the plant events cited by the alleger or others randomly selected for review created a safety
,
hazard such that a significant threat existed to the health
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and safety of the public. Further, no instance was iden-tified during the review where NRC reporting requirements had not been met, including those required by 10 CFR Part 21 or where NRC enforcement action was warranted but not taken.
The inspection did determine, that several areas of weakness do exist related directly or indirectly to some of the concerns expressed by the alleger where additional corrective measures are needed. These are documented in a separate report and were discussed with licensee management on May 3, 1982.
E.
Escalated Enforcement Action j
a.
Civil Penalties On September 8, 1980, the Senior Resident Inspector observed 2 of the 3 licensed operators on shift apparently sleeping. As a result of extensive investigations, inspections, management meetings and telephone meetings to research and analyze the circumstances surrounding this concern it was resolved that, although the operators may not have been sleeping, their
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conduct was contrary to the requirements of 10 CFR 50.54(k)
in that they were not attentive to their duties as licensed operators. A Severity Level IV violation and a Civil Penalty of $18,000 resulted.
b.
An $80,000 Civil Penalty was imposed for health physics program inadequacies which resulted in two personnel overexposures. A 22 rem overexposure occurred because of inadequate radiation surveys during the removal of a shield plug from the reactor vessel, and a 3 rem overexposure occurred because of an inadequate radiation evaluation during maintenance work unrelated to the 22 rem overexposure.
c.
Orders A single confirmatory order was issued which required the licensee to install and have operable a Scram Discharge Volume Continuous Monitoring System by December, 1980.
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The order was issued generically to all BWR licensees with a Scram Discharge Volume piping configuration similar to that which resulted in the control rod failure to scram at Brown's Ferry Station, and which resulted in the issuance of IE Bulletin No. 80-17.
There were no orders issued as escalated enforcement actions, d.
Confirmation of Action Letters (CAL-Formerly Immediate Action Letters (IAL)
i (1) A CAL was issued on December 4, 1980, to assure that adequate licensee corrective actions were taken, and that adequate interim surveillances were conducted,
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as a result of diffi. 1 ties in rendering the Scram Discharge 7olume Co:Linuous Monitoring System (See Paragraph c " Orders", above) operable.
(2) A CAL was issued on December 23, 1980, as a result of the Severity Level III violation of the Unit 3 Technical Specification which prohibits increasing reactor water temperature above 212*F with fuel in tha pressure vessel, and primary containment integrity requirements not met.
The CAL provided assurance that the operation of Units 2 and 3 would be modified to
prevent either design deficiencies in reactor instru-mentation and the Shutdown Cooling System, or procedural inadequacies, or both, from allowing a repeat of the unintended heatup from cold shutdown. Specific require-ments included procedure changes for operation of the Reactor Recirculation and Shutdown Cooling Systems; and a review for improvement to the design of the nuclear boiler temperature instruments; the shutdown cooling
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piping, valves, valve controls; or both.
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(3) A CAL was issued on September 4,1981, which confirmed licensee commitments to declare and maintain the Units 2'
and 3 High Pressure Coolant Injection (HPCI) systems in an inoperabic status until the problem of water accumula-tions in their steam supply lines was resolved.
Requirements for interim surveillances were also imposed, in addition to requirements to repair damage to HPCI steam supply piping support elements. The equipment was declared operable when it was demonstrated that piping suspension system repairs and newly installed drain lines remedied the problem. Long term analysis of potential fatigue problems were still continuing at the time this report was prepared.
(4) CAL's were issued on September 9,1981, and October 23, 1981, to document licensee corrective action commitments in response to observed damage to pipe support elements and other concerns surrounding the design, operation, and support of the Containment Cooling Service Water Systems for Units 2 and 3.
The CALs required the licensee to repair pipe hanger damage and to determine and correct the cause of the observed damage. The licensee repaired the damage and implemented changes to the syst.m's operating procedures to prevent further water hammer damage until a long term design evaluation could be completed. The design evaluation was not completed at the time this report was prepared.
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(5) Three CAL's were issued (November 20, November 25, and December 12, 1981) as a result of continued problems with inoperability of the 2 and 2/3 Emergency Diesel Generator Cooling Water Pumps. The CAL's were issued to assure that adequate licensee corrective actions were taken in regard to resolving the problem and that appro-priate interpretations of Diesel Generator operability and Technical Specification Limiting Conditions for Operation and Action Statements were in effect until the problem became resolved. The problem was resolved
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when the licensee replaced the broken check valves in
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the Cooling Water Pump Discharge Piping.
F.
Management Conferences (1) September 17, I?d(.; Messrs. C. Reed, J. Abel and other CECO representatives set with James G. Keppler, A. B. Davis, and members of the Region III staff to discuss the matter of es-calated enforcement options in regard to inattentive operators (see Paragraph 4, Item 8), and to discuss the circumstances surrounding allegations of missing water which was contaminated to a low level with radioisotopes.
(2)
M and members of the Region III staf f met with
.
Mr. J. O'Connor, Present, CECO on January 9, 1981, to resolve
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f issues surrounding the violation involving inattentive operators (see Paragraph 4, Item 8).
(3) Messrs. J. G. Keppler, R. Spessard, and members of the Region III staff met with CECO management and other memberss of CECO on December 23, 1981, to discuss NRC concerns of inadequacies in CECO response to events which occur at the Dresden Station, and matters pertaining to station security.
(4) On June 9, 1981, Mr. J. and members of the Region III staff met with Mr. B. Lee, Jr. and other CECO representatives to dist tss escalated enforcement sanctions in regard to incidents involving radiation overexposure to individuals at the Dresden Station (see Paragraph 4, Item 28).
(5) A second management conference was held on January 20, 1982, (after the appraisal period) to discuss enforcement sanctions resulting from an unplanned personnel exposure incident which occured in December 1981.
(6) On October 31, 1980, Messrs. J. G. Keppler, R. Heishman, and other NRC representatives met with Messrs. J. O'Connor, B. Lee,
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C. Reed, and other licensee representatives to discuss the results of the SALP 1 evaluation.
G.
Significant Licensee Activities (1) Unit 1 Outage Unit 1 was scheduled for chemical cleaning during this appraisal period. This activity was postponed until 1983 as a result of scheduling and financial considerations. The licensee returned the cicaning chemicals to the vendor because of shalf life considerations, and deactivated the chemical cleaning facility constructed for this project.
(2) The licensee committed a major portion of expended financial and other resources to meeting the various safety initiatives imposed upon nuclear power plants, including post-TMI require-ments and Inspection and Enforcement Bulletins and Circulars.
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H.
UNPLANNED REACTOR TRIPS Unit 2 Data Cause Description 07/27/80 Personnel Automatic Scram-Low Condenser Vacuum during Startup.
07/28/80 Personnel Automatic Scram-IRM's ranged down.
09/23/80 Equipment Automatic Scram-Turbine Trip due to loss of condenser vacuum from excessive air inleakage.
10/09/80 Equipment Automatic Scram-Turbine stop valve closure
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from EHC pump electrical malfunction.
11/20/80 Equipment Manual Scram-2B CRD pump tripped and restart failed.
11/24/80 Personnel Automatic Scram-Group 1 isolation during surveillance from M.S.L. High Flow test.
J 12/20/80 Equipment Automatic Scram-Turbine trip from moisture in turbine vibration meter.
12/04/80 Personnel Automatic Scram-IRM High High due to dropping HPCI speed; Operator response too slow to compensate for reactor pressure swing.
12/04/80 Personnel Manual Scram-Low Condenser Vacuum.
Pressure Regulator set too low-Operator misinterpreted bypass valve behavior.
12/11/80 Equipment Manual Scram-Scram discharge volume High-High level would not reset.
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06/13/81 Other Automatic Scram-Lightening caused electrical malfunction resulting in Group 1 and 2 isolation.
06/14/81 Personnel Automatic Scram-Low Condenser Vacuum during startup.
06/30/81 Personnel Manual Scram-Inadvertent recirculation pump trip while adjusting flow.
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Date Cause Description 07/15/81 Equipment Manual scram due to. Scram Discharge Volume contineous monitor High High alarm that would not clear.
08/15/81 Equipment Automatic Scram-With reactor critical and Main Turbine off the line, scram caused by erratic spike on IRM Channel 11.
09/21/81 Equipment Automatic Scram resulted during surveillance of one main turbine stop valve, all stop valves went shut.
09/22/81 squipment Automatic Scram resulted from spurious spike on IRM's Channels 11, 13, and 15.
'11/03/81 Equipment Automatic Scram due to IRM spike.
12/03/81 Equipment Automatic Scram-Reactor low water level.
12/13/81 Equipment Automatic Scram-Reactor low water level.
Unit 3 Date Cause Description 08/01/80 Equipment Automatic Scram-Low Reactor water level when 3B Feedwater Regulating valve went shut.
08/29/80 Equipment Automatic Scram-Low Reactor water level when 3B Feedwater Regulating valve went shut and 3C Reactor Feed Pump minimum
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flow valve went open.
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l 08/30/80 Personnel Automatic Scram-High neutron flux when (
the turbine tripped due to moisture
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separator drain tank high high level
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while resetting heaters 10/24/80 Equipment Automatic Scram-E.S.S. MG tripped and APRM's went upscale.
11/26/80 Equipment
. Automatic Scram-Group 1 isolation when
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Reactor mode switch contacts did not make up properly when placed in startup from run and reactor pressure dropped below 850 psi during normal shutdown.
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Date Cause Description 01/01/81 Equipment Automatic Scram-Turbine trip due to 3A moisture separator tank high high water level.
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01/05/81 Equipment Automatic Scram-Trubine trip due to 3A moisture separator tank high water level.
02/23/81 Equipment Automatic Scram-3B recirculation MG set spiked high causing APRM's to spike high.
04/17/81 Equipment Automatic Scram-Contractor employ dragged
scaffolding across the MS high flow detector switch resulting in a Group 1 isolation and Scram.
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