IR 05000206/1991016
| ML13329A156 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 10/03/1991 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML13329A155 | List: |
| References | |
| 50-206-91-16, 50-361-91-16, NUDOCS 9110220116 | |
| Download: ML13329A156 (26) | |
Text
U. S. NUCLEAR REGULATORY COMMISSION
REGION V
SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE INITIAL SALP BOARD REPORT Nos. 50-206/91-16, 361/91-16, 362/91-16 SOUTHERN CALIFORNIA EDISON COMPANY SAN ONOFRE NUCLEAR GENERATING STATION FEBRUARY 1, 1990 THROUGH JULY 31, 1991 9110220116 911003 PDR ADOCK 05000206 G
TABLE OF CONTENTS Page I. Introductio.
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II. Summary of Results...................
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A. Overview..
B. Results of Board Assessment.....
III. Performance Analysis..................
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A. Plant Operations...................
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B. Radiological Controls................... 6 C. Maintenance/Surveillance.................. 8 D. Emergency Preparedness................... 11 E
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Security...........
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............. 13 F. Engineering/Technical Support.........
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G. Safety Assessment/Quality Verification........... 18 IV. Supporting Data and Summaries................. 21 A. Licensee Activities.21 B. Inspection Activities...............23 C. Enforcement Activities..................
D. Confirmatory Action Letters..............
E. Licensee Event Reports.................
I. INTRODUCTION The Systematic Assessment of Licensee Performance (SALP) is an integrated NRC staff effort to collect available observations and data on a periodic basis and to evaluate licensee performance based on this information. The program is supplemental to normal regulatory processes used to ensure compliance with NRC rules and regulations. It is intended to be sufficiently diagnostic to provide a rational basis for allocating NRC resources and to provide meaningful feedback to licensee management regarding the NRC's assessment of their facility's performance in each functional are An NRC SALP Board, composed of the members listed below, met in the Region V office on September 11, 1991, to review observations and data on the licensee's performance in accordance with NRC Manual Chapter 0516,
"Systematic Assessment of Licensee Performance."
This report is the NRC's assessment of the licensee's safety performance at San Onofre for the period February 1, 1990 through July 31, 199 The SALP Board meeting for San Onofre was attended by:
Board Chairman R. Zimmerman, Director, Division of Reactor Safety and Projects, RV Board Members K. Perkins, Deputy Director, Division of Reactor Safety and Projects, RV J. Dyer, Director, Project Directorate V, Division of Reactor Projects, NRR G. Yuhas, Chief, Reactor Radiological Protection Branch, RV D. Kirsch, Chief, Reactor Safety Branch, RV P. Johnson, Chief, Reactor Projects Section 3, RV G. Kalman, Unit 1 NRR Project Manager L. Kokajko, Units 2 and 3 NRR Project Manager C. Caldwell, Senior Resident Inspector, San Onofre Other Attendees R. Huey, Chief, Engineering Section, RV J. Reese, Chief, Safeguards, Emergency Preparedness and Non-Power Reactors Branch, RV P. Qualls, Emergency Preparedness Analyst, RV D. Schuster, Safeguards Inspector, RV D. Chaney, Radiation Specialist, RV A. Hon, Resident Inspector, San Onofre C. Townsend, Resident Inspector, San Onofre K. Johnston, Project Inspector, RV C. Holden, NRR
II. SUMMARY OF RESULTS A. Overview The licensee's performance during this SALP period continued to demonstrate a professional and responsible approach to operation of the San Onofre Nuclear Generating Station. Strong management involvement was evident in many area Few operational events were encountered, and operators responded effectively to those which did occur. However, management and staff were at times not sufficiently effective or self-critical in dealing with plant problems and emergent issue Continued strong performance was observed in three functional areas (Radiological Controls, Emergency Preparedness, and Security) which were again rated Category 1. Three other areas (Plant Operations, Engineering/Technical Support, and Safety Assessment/Quality Verifi cation), although again assigned a Category 2 rating, demonstrated an improving trend. The Maintenance/Surveillance area, rated Category 1 during the previous period, was assigned a Category 2 ratin Management took aggressive action near the middle of the assessment period to address excessive on-line maintenance and other issues which were distracting operator attention from plant operational activities. This distraction appeared to contribute to a violation for which a civil penalty was issued in January 1991. The new Operations Manager was also very effective in addressing Units 2/3 operator attrition and weak communications observed during the early portion of the perio Several significant maintenance efforts were undertaken and successfully completed during this period. Weaknesses were never theless observed in effectively implementing maintenance program controls. These weaknesses involved work planning, post-maintenance testing, and attention to proper performance of maintenance activities. Maintenance management was also not sufficiently self critical in assessing and correcting identified weaknesse Most engineering design activities and major engineering efforts (e.g., thermal shield repair) were well planned and execute However, engineering work on shorter term or emergent issues was on occasion less thorough or effective, with a tendency toward expedi ency. Improvement was noted in the quality of licensing submittals, although timeliness was of concern. The Nuclear Oversight organiza tion was increasingly involved in station activities, as evidenced by aggressive and perceptive audits and proactive safety assessments of plant evolution Overall, the licensee's management and staff were found to be well qualified and committed to safe operation of the San Onofre Statio Many of the improvement programs instituted during the previous assessment period had taken effect. However, a more deliberate approach and additional attention to the implementation of established programs were neede B. Results of Board Assessment Overall, the SALP Board found the performance of NRC licensed activities to be acceptable and directed toward safe operation of the San Onofre Station. The SALP Board has made specific recommendations in most functional areas for licensee management consideration. The results of the Board's assessment of the licensee's performance in each functional area, along with the results from the previous period, are as follows:
Rating Rating Last This Functional Area Period Period Trend A. Plant Operations
2 Improving B. Radiological Controls
1 C. Maintenance/Surveillance
1 E. Security
1 F. Engineering/Technical
2 Improving Support G. Safety Assessment/
2 Improving Quality Verification III. PERFORMANCE ANALYSIS The following is the Board's assessment of the licensee's performance in each of the functional areas, along with the Board's conclusion for each area and its recommendations with respect to licensee actions and management emphasi A. Plant Operations 1. Analysis During the SALP period, approximately 30 percent of total direct inspection effort was applied in the Plant Operations area. A strength continued to be the operators' ability to promptly and correctly diagnose and respond to plant events. Management was also aggressive in addressing operational weaknesses observed during the first half of the assessment period. These weaknesses were in operational performance, principally involving a heavy administrative workload on operators, declining operator staffing levels, and a consequent reduction in operator attention to the monitoring of plant statu However, the licensee initiated corrective actions for these issues by the latter portion of the period. A minor weakness was noted in training and qualificatio This functional area was rated Category 2 during the previous SALP period. In response to the last SALP Board recommenda tions, the licensee, for the most part, conservatively interpreted and applied Technical Specification (TS) require ments during this period. In addition, the licensee provided
continued management emphasis during this period on procedure compliance and operator performance of routine plant evolution However, progress of the licensee's efforts in response to other recommendations, such as work control, staffing levels, and training, did not become evident until the latter part of this assessment perio The operators performed well in response to operational events with prompt and correct diagnoses, followed by proper corrective actions. The operators recognized the closure of a Unit 1 main feedwater regulating valve and tripped the reactor before steam generator (SG) levels reached the reactor trip setpoint; tripped Unit 2 in response to a loss of reactor coolant pump (RCP) seal flow, despite conflicting seal flow indications; and recognized and terminated an inadvertent draindown of the Unit 3 spent fuel pool before level reached the alarm setpoin During the early part of this assessment period, Unit 2/3 per formance in Plant Operations was impacted by high operator attrition, heavy overtime usage, heavy administrative workload to support on-line maintenance activities, and poor communica tions between operators and management. These factors contributed to reduced operator attentiveness that resulted in two equipment alignment errors which remained undetected for some time. One involved an open Unit 3 emergency sump outlet isolation valve, which compromised containment integrity and rendered one safety injection and containment spray train inoperable. The other involved an isolated steam trap which rendered the Unit 2 turbine driven auxiliary feedwater pump inoperable. Although these misaligned valves were later identified by the licensee and there was no actual safety impact, the NRC considered them to have contributed to a significant reduction in the overall margin needed for safe operation of the plant. As a result, they were cited as Severity Level III violations and prompted the issuance of a civil penalty in January 199 In response to observed operational problems, including those addressed by the civil penalty, licensee management initiated aggressive corrective actions to address these issues. These included a reduction in on-line preventive maintenance, provi sion of additional time at the beginning of each shift for operators to thoroughly walk down the control boards, and more effective communications between management and operators. The newly appointed Operations Manager was observed to be very effective in implementing these improvements. Significant progress was observed in these areas in 1991, as evidenced by improved operator performance and moral The licensee was generally conservative in the identification and resolution of technical issues. One example was the deci sion to shut.down Unit 2 for SG sparger repairs after erosion was found in Unit 3 SGs. However, the licensee was observed to incorrectly interpret TS requirements on one occasion. When
Unit 1 control rods could not be electrically inserted (although they were trippable), the licensee did not declare the control rods inoperable until prompted by the NR Four enforcement items were attributed to Plant Operations -
the two Severity Level III violations previously discussed, plus two Severity Level IV violation Some operational events were attributed to causes under the licensee's control. Two of the eight reactor trips resulted from maintenance or surveillance error. Two others were caused by failures of Unit 2/3 non-1E uninterruptible power supplies, a design weakness which has caused several spurious trips in recent years. Following the last of these trips (in March 1991), the licensee implemented a design change to alleviate this weakness. Although improved performance was observed over the previous SALP assessment, operator errors occasionally occurred during routine plant evolutions. Some of these errors involved human factors issues (e.g., containment mini-purge misalignment), while others involved insufficient operator attention (e.g., failure to identify an improperly locked circuit breaker in Unit 1).
Operating procedures were generally well written and prepared by personnel with extensive operational experience. Control of these procedures was maintained using a state-of-the-art computer information system. However, occasional procedure deficiencies resulted in events and TS violations, such as the inadvertent draindown of the Unit 3 spent fuel pool, the mis aligned AFW pump turbine steam trap, and insufficient instruc tions for locking the circuit breaker discussed abov In the area of training and qualification, the licensee initi ated the Professional Operator Development Program to enhance overall operator performance. Although Unit 1 operator license candidates had a 100 percent pass rate, initial license candi dates for Units 2 and 3 had a pass rate of 80 percen Evaluation of the Units 2 and 3 requalification program found it to be satisfactory. One weakness observed in the operator training program, however, was insufficient familiarity with the functional recovery procedures. In response, the licensee promptly initiated corrective action The licensee was considered to have a relatively strong fire protection program, including a dedicated onsite fire department with hazardous material handling capability. On-scene personnel responded well to a generator exciter fire which occurred during the SALP perio. Performance Rating Performance assessment - Category 2, Improving Tren. Board Recommendations The Board recommends continued strong management support of the Operations staff to promote close monitoring of plant condi tions. Continued management attention to proper application of Technical Specification requirements is encouraged. The licensee should also continue to enhance operator development and training programs and the quality of operating procedure B. Radiological Controls 1. Analysis Inspections of the chemistry and radiation protection programs during this SALP period found that the licensee has continued to be proactive in ensuring excellence and quality in both program areas. Approximately 7 percent of total inspection effort during the assessment period was devoted to this functional are The licensee's performance in this functional area during the previous SALP period was rated Category 1. The previous SALP Board recommended that the licensee continue efforts to ensure active participation of all site organizations in a quality health physics (HP) program, to improve the quality of HP audits, and to maintain periodic retraining for HP disciplines such as respiratory protectio These recommendations were met, in part, by effective use of personnel resources, manager development, comprehensive audits, innovative concepts for radiological work practices training, and continued evaluation and redirection of supervisory and management resources. The licensee's development of specially qualified project managers for key functional positions has freed technical program supervisors from the day-to-day rigors of program managemen During this period the licensee also implemented several train ing programs (Management and Supervisory Development, Team Building, Coaching and Mentoring) to improve the HP Department's image and functional interaction with other SONGS department Evaluation and development of state-of-the-art equipment was continually ongoing. Procurement of state-of-the-art respirator and respiratory filter testing equipment was one example of the licensee's ability to realize dividends from the purchase of expensive equipment. Construction of the advanced radiological worker training mockup was added evidence of licensee foresigh Management involvement was very evident in the areas of chemistry, effluent controls, radioactive waste management, transportation of radioactive materials, work area radiological controls, training of radiological workers and technical staff, and quality assurance audits and program assessments. SONGS
workers and technical staff persons were held to high standards of performance. HP-related procedures were logically written and properly controlled; very few incidents were attributed to procedural shortcomings. Records and plant performance data were generally complete, well maintained, and readily availabl Licensee performance in the areas of effluent control, effluent monitoring, and radioactive waste management was maintained at a high level except for the several noted deficiencies related to special processing of radioactive oils (mixed wastes) between November 1988 and January 199 The licensee routinely exhibited a thorough understanding of technical issues, and the approaches to issue resolution were sound. Excellent planning and assignment of priorities were consistently evident during complicated evolutions such as Unit 2/3 steam generator feed ring repairs, Unit 1 thermal shield support modifications, and Unit 2/3 spent fuel pool reracking, as well as in the creation of a task force to identify and evaluate controls over all site effluent release paths. In the area of radiological controls, the licensee's overall approach to resolving technical issues showed a high degree of conservatis Seven non-repetitive violations (including two non-cited) were identified during this period. These violations involved a missed chemistry surveillance, high radiation area key control, radioactive waste management, FSAR updates, radioactive material control, labeling, 10 CFR 50.59 reviews, and transportation activities. Corrective actions were timely. The effectiveness of root cause analyses was evidenced by a lack of recurring violations. The licensee's enforcement history during this period did not indicate any programmatic breakdown No significant operational events involving either chemistry or radiation protection occurred during this period. Licensee event reports were submitted in a timely manner, and analyses were normally thorough and accurate. However, the licensee did not maximize the potential benefit of corrective actions by consistently incorporating them at all unit Staffing levels and personnel qualifications in the licensee's chemistry and radiation protection organization were considered superior. Vacant key positions were filled on a priority basi The licensee effectively utilized management resources to free the HP technical support staff from task scheduling and management. Frequent use of rotational assignments within the HP technical and HP technician supervisory groups kept the organization well rounded in all areas of radiation protection expertis Training and qualification programs for each functional group (radiochemistry, cold chemistry, effluent engineers, HP techni cians, radioactive waste, radioactive material control, and
dosimetry) were well implemented. The licensee maintained high standards for the training of SONGS radiological workers and technical staff. Quality control measures for individual training programs were effective in maintaining training current to facility and industry changes. Inadequate training could rarely be traced as a root cause of minor events or problems occurring during the assessment period. Except for minor discrepancies in the contract dosimetry clerk qualification program, qualification programs were well implemented and moni tored by plant management. Routine newsletters inform the sta tion staff of problems and achievements within the radiation protection grou. Performance Rating Performance Assessment - Category. Board Recommendations Management should continue to provide full support to site and corporate staff initiatives to maintain and improve the present performance level of chemistry and radiation protection pro grams. Emphasis should be directed toward ensuring that faci lity upgrades, such as the south yard project, are completed and that long-term and temporary contractors benefit fully from formal training programs. Additionally, the licensee should be particularly sensitive to performance in those areas wherein management positions have been filled by individuals who do not have a strong health physics backgroun C. Maintenance/Surveillance 1. Analysis The Maintenance/Surveillance functional area was observed routinely during the assessment period by resident and regional inspection personnel. Approximately 24 percent of the inspec tion resources were applied in this functional area. Strengths included quality routine maintenance, generally accomplished right the first time, significant maintenance activities com pleted without difficulty, effective planning of surveillance tests, and the use of state-of-the-art equipment for diagnostics and troubleshooting. Observed weaknesses included excessive on-line maintenance, weak implementation of work controls, post maintenance testing, and insufficient attention to detail in the performance of maintenance activitie Licensee performance in this functional area during the previous SALP period was rated Category 1. However, the Board recognized a continued need to improve implementation of the maintenance program, especially regarding attention to detail and procedural implementation. The Board also recommended strengthening the
work order preparation and planning process, and increasing supervisory review of maintenance activitie The licensee continued to perform well in the conduct of routine and complex maintenance activities such as the Unit 1 thermal shield repair and the Unit 3 generator hydrogen leak repai Other significant maintenance activities which were accomplished with minimal problems included diesel generator (DG) overhauls and the Unit 1 reactor coolant pump 'C' rotor replacemen However, weaknesses in training and experience appeared to be a factor in maintenance and technical personnel not recognizing abnormal air leakage from the Unit 1 auxiliary feedwater steam supply valve (CV-113) prior to its failur The licensee maintained an effective surveillance scheduling program during this period, with very few missed surveillance tests. Surveillance program weaknesses were noted, howeve One surveillance procedure did not adequately test the Unit 1 Safety Injection Signal/Loss of Offsite Power circuitry for all assumed condition Missing cable separation blankets, prescribed by Regulatory Guide 1.75, were not identified due to lack of a surveillance program. Also, weaknesses in the inservice inspection program were identified by a special NRC inspection conducted shortly after the end of the SALP perio Another observed strength was the licensee's use of state-of the-art equipment such as the Electronic Characterization and Diagnostics (ECAD) system for electrical troubleshooting. In addition, a Maintenance Estimating Standards Program was initiated as a maintenance scheduling too Formal communica tions training was also given to all maintenance personnel to promote program understanding and adherence to procedure During the last SALP period, San Onofre was a pilot plant in developing a Reliability Centered Maintenance (RCM) program for scheduling preventive maintenance. One of the objectives of this effort was to support an effective on-line maintenance program, but it was discontinued after completion of the pilot project. Subsequently, the licensee recognized the benefit of the RCM program and assigned it to Maintenance for developmen Assessment of this program has not yet been possibl Early in the SALP period, the licensee implemented a program to schedule on-line preventive maintenance activities on safety related systems utilizing the provisions of TS limiting condi tions for operation (LCOs). This program considered equipment vendor recommendations, and sought to distribute the maintenance workload between plant operation and refueling outage Although well-intentioned, the significant increase in equipment outages during power operation distracted operator attention from plant operation and caused reduced system availability. In response to NRC concerns and Nuclear Oversight organization
findings, the licensee reduced on-line maintenance during the latter half of this SALP perio Management was closely involved with maintenance activitie Plant material conditions and housekeeping were generally good, with occasional exceptions noted. For example, foreign material exclusion (FME) difficulties and subsequent investigations indicated the need for a more critical self-assessmen Maintenance Division investigations were generally effectiv Several plant events resulted from additional weaknesses in work order planning, preparation, and control processe For example, an inadequate work authorization record (WAR) and maintenance order (MO) resulted in an inadvertent start of a Unit 1 diesel generator (DG).
Another example (which occurred in 1989 but was identified during this SALP period) was the improper assembly of a containment spray flow control valve (CV-518) in Unit 1, which was the subject of an enforcement conference. Late in the period, an inadequate maintenance procedure and insufficient familiarity with equipment may have contributed to a failure of AFW valve CV-113. Additionally, delayed repair of backflush valves in the salt water cooling (SWC) system resulted in one heat exchanger being excessively removed from service for cleaning. Had the backflush valves been repaired promptly, the increased unavailability of this important system, which could have adversely affected plant safety, would have been avoide Most reportable events attributed to the maintenance area were the result of personnel errors. A number of these indicated a continuing weakness in individual attention to detail and in procedure implementation. One example was an actuation of the Unit 2 containment spray system, which occurred when technicians inadvertently omitted the steps on one page of the procedur To address some of these issues, formal communications training was given to all maintenance personnel and the licensee initiated a work authorization task force and a procedure upgrade program. The NRC has not yet assessed the effectiveness of these initiative Post maintenance testing (PMT) was observed to be an area in which improvement was warranted. Some deficiencies encountered could have been prevented by a thorough and aggressive PMT. For example, inadequate maintenance on a backup nitrogen regulator, which made a Unit 3 atmospheric dump valve inoperable, might have been identified by an effective PMT. Subsequent to this and other problems, the licensee committed to create a retest committee to ensure appropriate functional testing. However, these corrective actions were not fully effective. For example, failure to involve the Retest Committee on one occasion near the end of the assessment period allowed the inoperable Unit 1 AFW pump steam supply valve, CV-113, to be prematurely returned to service. In addition, Retest Committee controls were incorporated into station procedures in a manner which caused
this commitment to be improperly implemented on a number of occasion Five maintenance-related Severity Level IV violations and one deviation occurred during this SALP period. These were minor in nature and were not indicative of programmatic breakdow Staffing was generally adequate, comprised primarily of jour neyman level personnel. A relatively high attrition rate was observed in the Unit I Maintenance Department, with most personnel moving to the Units 2/3 maintenance organization The maintenance staff was supplemented with contract personnel as necessary. Maintenance training was generally good, providing extensive hands-on exposure to good mock-ups and other training material. Performance Rating Performance Assessment -- Category. Board Recommendations The Board recommends that the licensee continue to encourage individual attention to detail in the conduct of maintenance and surveillance activities. Licensee management should also continue to focus attention on implementation of the post-main tenance testing program, the quality of maintenance procedures, implementation of the work control process, and the quality of maintenance training. Continuation of licensee initiatives such as the work authorization task force and the RCM program is encouraged. Consideration of safety importance should also be given additional emphasis in the scheduling of maintenance activitie D. Emergency Preparedness 1. Analysis The emergency preparedness functional area was assessed during four routine inspections and by observation of the annual exer cise. Approximately 3 percent of the total inspection effort was devoted to the licensee's emergency preparedness progra The licensee received a SALP Category 1 rating in this area during the last appraisal period. The last SALP board recom mended continued support of the licensee's drill and audit programs. Strengths identified during the current assessment period included continued management support of the emergency preparedness program and a good relationship with offsite jurisdictions. No significant weak areas were identified; however, a concern was identified with the retraining of the emergency response staf Upper management demonstrated continuing support of the Emer gency Preparedness (EP) program by providing the resources necessary to implement enhancements in the EP Program. During this period, for example, the licensee voluntarily initiated implementation of the Emergency Response Data System (ERDS);
improved the prompt notification system; implemented an auto mated recall system to expedite personnel recall; and made a videotape to train drill controllers, copies of which were requested and provided to two dozen other utilities, INPO, and the State of California. Licensee management also provided the manpower and resources necessary to conduct an aggressive drill and exercise program. Management demonstrated support of off site agency relations by making additional agreements with the California Highway Patrol (CHP) for their use of the San Onofre EOF during certain closures of Interstate 5; by working with the newly incorporated city of Dana Point to integrate them into the SONGS emergency plan and develop an emergency plan for Dana Point; and by continuing to support the Interjurisdiction Planning Committee (IPC) and to correct problems identified in the monthly IPC meeting The October 1990 exercise demonstrated a number of strengths in the licensee's ability to protect the public in a postulated severe accident. Licensee personnel were able to interface, communicate, and perform well with NRC counterparts in their efforts to mitigate the consequences of the postulated even The licensee's Quality Assurance audit for 1990 was of broader scope and depth than the preceding year's audit. An EP super visor from Palo Verde assisted in development of the audi Corrective actions identified were tracked as needed. The licensee also made arrangements for participation of a Consoli dated Edison EP engineer in the 1991 audit. The licensee instituted a computer program, GENTS, for use in tracking identified weaknesses in drills and exercises. The effective ness of this program has not been evaluated, since it was implemented at the end of the SALP perio When technical issues were identified the licensee showed a clear understanding of the issues involved. When potential safety significance existed, the licensee routinely exhibited a conservative attitude. Resolutions were generally timely and sound, and problems have seldom recurred. Examples included the correction of problems identified during exercises, and improvements in the prompt notification telephone system and in the methodology used to respond to inoperable sirens. However, a problem with public address speakers and acoustics in the spent fuel building was identified during a July 1991 even This made emergency announcements unintelligible in the build ing, and was still unresolved at the end of the SALP perio One Severity Level IV violation was cited early in the SALP period, for failure to conduct a post-accident sampling system (PASS) sample exercise during 1989 (the previous SALP period).
Three non-cited violations were also identified. The non-cited violations involved failure to evaluate the adequacy of the interface with offsite agencies, a late notification of inoper able emergency sirens, and failure to document repairs to the emergency notification telephone as required by procedures. No LERs involving EP activities were generated during this perio The licensee had four opportunities to exercise the Emergency Plan, involving four unusual events which occurred during this period. These involved two seismic monitor actuations, an onsite fire, and a fire on Camp Pendleton. The licensee correctly and conservatively classified the event in each cas The licensee continued to provide adequate levels of dedicated staff to implement the programs and to interact with local offsite agencies. EP staff and emergency response positions were clearly identified, and authorities and responsibilities are clearly defined. The licensee added two nuclear engineers to the EP staff to augment the available technical expertis Staff expertise was also enhanced by participation in audits at Palo Verde and INPO, and by an inter-utility exchange with Fort Calhou The licensee's training program for the emergency response staff generally met NRC requirements. The licensee identified a weak ness in the emergency response staff training program, as indicated by a high percentage of exercise and drill deficien cies attributed to training. A contributor appeared to be the annual computer-based requalification training, which lacked performance-based attributes. To address this issue, toward the end of the SALP period, the licensee started giving tabletop exercises to the emergency response staff. The licensee also initiated corrective actions in the technical support and health physics areas which have not been completed or assessed as of the end of the perio. Performance Rating Performance Assessment - Category. Board Recommendations The Board recommends that management provide continuing atten tion to improving the effectiveness of emergency response staff training and maintain its support of the EP corrective action and offsite programs. The board also recommends that the licensee continue efforts to improve PA system performanc E. Security 1. Analysis Inspections conducted during this SALP period found the licensee to have been proactive and innovative in assuring continued
quality in their approach to enhancing securit The previous SALP report rated the licensee Category 1 and recommended continued support of security program enhancements; e.g., licensee initiatives to address Unit 1 Vital Area barrier weaknesse During this SALP assessment period, Region V conducted three physical security inspections at the San Onofre Nuclear Genera ting Station. Approximately 2 percent of the total direct inspection effort was expended in this functional area. In addition, resident inspectors provided continuing observations in this are Corporate and plant management continued to be involved in assuring quality and in reviewing the operation of the overall security program. This remained a strength, as in the previous SALP period. This was further reflected in the licensee's approach to the identification and resolution of technical issues from a safety, as well as a security, standpoint. The licensee took prompt action to modify their search train equipment in response to a technical issue, before issuance of an NRC Information Notic The licensee's audit of the personnel screening program was considered noteworthy. Findings resulted during this audit because the auditor persisted in following suspected weaknesse The licensee took prompt action to correct the identified deficiencie Two violations, licensee-identified and not cited, occurred during the SALP period. One violation pertained to three security officers found not to have had physical examinations within the required twelve month period. The other involved emergency vehicles found in the protected area without th required security escort. Both appeared to be isolated incidents and have not recurred. There was one licensee reported event during this period, pertaining to loss of power to the security monitoring system which provides audible and visual indication to the alarm stations of protected and vital area intrusion detection. The licensee took prompt and appropriate actio The licensee submitted copies of the safeguards event log on a quarterly basis as required, indicating a lower than average number of security events, attributed to both human and hardware failures. A security trend committee met once each quarter to determine causes and recommend corrective action. In addition, the Manager of Station Security regularly informed station management of security infractions caused by personnel within each segment of the station organization. Other managers have taken steps to readjust goals as a further effort to reduce the
number of security-related events. It was further noted that SONGS has a relatively low number of security related event During a past NRC Regulatory Effectiveness Review, weaknesses were indicated in Unit 1 vital area (VA) barriers. Although the licensee was meeting Security Plan requirements, the licensee indicated that they would again review the barriers for Unit As a result of this study, several proactive security upgrades were initiated. Senior management has been actively involved in establishing priorities and necessary funding. Significant starts have occurred in all areas targeted for upgrad Licensee staffing of the security program has been a strength during this period as it was in the previous SALP period. The organization appeared well defined, with responsibilities and authorities appropriately detailed. Decision making authority appeared properly delegated to ensure quick identification of and response to problems and changes. An attitude was evident at San Onofre that security is "our responsibility," not "their responsibility". This was best illustrated by the completion of two major projects:
(1) the Vital Area Penetrations project, requiring many modifications of the heating, ventilation, and air conditioning system and (2) the Target Analysis portion of the security upgrade program. These projects required the combined efforts of the Nuclear Operations, Engineering and Security Department A strength from the previous SALP period was the licensee's security training and qualification program. Instructors were observed during actual classroom and range firing presentations, and appeared highly qualified, motivated and professional. The security training organization was actively involved in increased tactical drills as part of the security upgrade program. Here again, management was involved in providing the necessary funding to support this additional trainin An additional licensee initiative, already funded, is the establishment of a security training compound, scheduled to start in late 199 The licensee anticipates that this com pound, when completed, will facilitate increased performance based training for security officer The licensee's Fitness for Duty (FFD) program appeared to meet the requirements of 10 CFR Part 26. Though not formally inspected during this SALP period, reviews of required FFD reports and informal reviews of FFD staff and facilities indi cated the FFD program to be comprehensive and well understood by the general site populatio. Performance Rating Performance Assessment -- Category. Board Recommendations Licensee management should continue to support the security upgrades progra F. Engineering/Technical Support 1. Analysis During the SALP period, approximately 13 percent of the NRC's inspection effort at SONGS was applied in the Engineering/
Technical Support functional area. This included routine inspections by the resident inspectors, one setpoint methodology team inspection, and eight engineering inspection The principal strength was the licensee's aggressiveness in implementing engineering program enhancements, which led to engineering design change improvements, successful technical implementation of major evolutions, a thorough single failure analysis for Unit 1, and the discovery of a number of design basis deficiencies. Weaknesses involved incorrect engineering assumptions, inadequate technical reviews, and discrepancies in setpoint methodology and design contro Licensee performance in this functional area during the previous SALP period was rated Category 2. The Board noted at that time that the licensee had been aggressive in enhancing engineering and technical performance. During the current SALP period, the licensee appeared to have successfully implemented past recom mendations by continuing to aggressively pursue engineering program enhancements, such as the design basis update and technical sufficiency improvements. One exception noted was setpoint methodology, an area in which additional weaknesses were identifie A number of existing design deficiencies were identified by the licensee's design basis documentation efforts. These included nonconservative reactor vessel refill volumes (a safety injection refill delay) which had been previously used for the UFSAR Chapter 15 analyses. The emergency core cooling system analysis and the design basis documentation effort were performed by licensee personnel, contributing to in-house knowledge of the plant design basis and raising the expertise available within the staf Management involvement and prior planning were evident in the Engineering and Construction organization's success in accomp lishing complex technical efforts. Examples of these efforts included the completion of thermal shield repairs with only minor technical concerns, successful implementation of the spent fuel pool reracking project, and completion of the Unit 1 480 Volt Bus realignment. Design change packages (DCPs) implemented during the Unit I Cycle XI refueling outage were found to have
been well prepared and appeared to have been properly installed and tested, with only minor discrepancies note In general, conservatism, sound approaches and understanding of issues were apparent. The engineering organization was still aggressive in finding and correcting long-standing technical problems. The methodology employed in the licensee's Unit 1 single failure analysis (SFA) was also observed to be comprehensive and thorough. The SFA modifications were generally well engineered, correctly implemented and adequately tested, with good supporting documentation. However, some assumptions such as the treatment of check valves and relief valves as passive components in the Unit 1 single failure analysis, were not consistent with current industry practic In addition, all relevant assumptions were not included in the original calculation for initiation of hot leg recirculatio These appeared to be of minor safety significanc In general, engineering and technical activities associated with shorter term or emergent issues were less effective. In some cases, this appeared to involve a tendency toward expediency or to underestimate the scope or complexity of the problem. For example, technical assessment of the Unit 2 AFW pump overspeed trip initially failed to reveal that the steam traps were closed and that the pump was inoperable. Moreover, Station Technical did not consider the reserve capacity of the associated backup nitrogen supply in their failure assessment of CV-113. The technical review process also failed to identify discrepancies and administrative errors -- for example, equation errors in calorimetric and reactivity balance procedures. Further review by the licensee of similar nuclear engineering procedures revealed format errors elsewher The setpoint team identified weaknesses in the setpoint control program, and concluded that additional supervisory overview was needed. For example, errors in Units 2/3 steam generator (S/G)
level setpoint calculations resulted in level setpoints below those allowed by the TS. In addition, an error associated with fluctuation of a containment pressure indication was not accounted for in the setpoint calculation for the Anticipated Transient Without Scram/Diverse Scram System. NRC reviews also identified a TS amendment request based partially on an inaccurate document which had not been properly reviewe Further some Unit 2 Cycle V Core Protection Calculator calcula tions were performed using Cycle IV dat Design control was generally good. However, some weaknesses were noted, including the lack of a program to control the use of operator aids in the control room. A weak interface between Operations and Station Technical was also noted in one instance involving changes to core protection calculator (CPC) address able constants. Improvement was noted in the quality of engineering work supporting licensing actions and generic correspondence, although timeliness was of concer Staffing for Nuclear Engineering and Construction was enhanced by increased staffing levels and by transferring engineers from Station Technical. The Station Technical organization compen sated for this by the hiring of new engineers. However, the staffing levels in Engineering and Station Technical contributed to difficulties with work backlog and overtime during most of the SALP period. The emphasis on using staff engineers, contributing to in-house knowledge of the plant design basis, was apparent in the quality of the emergency core cooling system analysis and the design basis documentation effort. Training enhancements also improved the overall quality of engineering and technical work during this assessment perio Enforcement items this period included six Severity Level IV violations. These were minor in nature and did not indicate programmatic breakdow. Performance Rating Performance Assessment -- Category 2, Improving Tren. Board Recommendations The licensee should strengthen the effectiveness of engineering and technical work on emergent issues and day-to-day plant problems. The Board also encourages licensee management to provide continuing support to engineering program improvement Additional emphasis should be placed on ensuring proper calcu lational assumptions, strengthening technical reviews, and continuing the development of the setpoint methodology progra G. Safety Assessment/Quality Verification 1. Analysis During the SALP period, approximately 19 percent of total inspection effort was applied to this functional area, and ongoing assessment was provided by NRR. The principal strength identified was the licensee's continued aggressiveness in building an effective Nuclear Oversight organization. Results of this effort were observed in the second half of the SALP period, as evidenced by detailed root cause assessments, proactive audits, detailed outage plans, and enhanced plant monitoring. Weaknesses in this functional area included a need for continued development of a questioning attitude among all personnel, attention to detail in implementing various aspects of the corrective action program, and timeliness of licensing submittal The licensee was rated Category 2 in this area during the pre vious SALP period. During this period, the licensee remained aggressive in enhancing oversight programs. This included defining and working diligently toward a clear set of goal Staffing was further enhanced by broadening the expertise and by cross-training of personnel. A commitment to improvement was also demonstrated by involvement in industry initiative During this SALP period, the licensee completed implementation of the root cause assessment program and staffed the Safety Engineering organization. Large scale root cause determinations were observed to be very extensive and effective, although some root cause determinations at the division level were not as successful the first time. A well designed training program was implemented for technical and oversight personnel to support the root cause program. Investigations were still mostly reactive, with detailed assessments performed in response to enforcement items, plant trips, or events. However, the root cause program was becoming more proactive, making assessments of programs and organizational structures. In addition, the Quality Engineering organization performed independent technical and analytical assessments of a few design changes and the design change process. In general, these assessments were critical of organizations and programs, and identified areas in need of additional management attentio The QA audit program demonstrated increased maturity during this assessment period. QA audits were more proactive and deliberate, and resulted in notable findings. One example was an audit of control room instrument lumigraphs, requested by the Unit 2/3 Operations Superintendent. Comprehensive audits of radiological protection and chemistry programs and of security background investigations also produced very meaningful findings. Corrective actions were developed and implemented in a timely manner, and the lack of repetitive events indicated that corrective actions were effective. The tracking and trending of audits was a weakness, although the licensee was working to enhance the associated data bas The licensee also initiated nuclear oversight outage plans during this assessment period. A Unit 1 refueling and thermal shield repair outage plan was prepared that included a probabi listic risk assessment (PRA) study for important evolutions during the outage. This PRA identified the potential for high radiation exposures if an inadvertent draindown of the refueling cavity should occur. This led to the implementation of an hourly cavity level watch, which identified an actual draindown of the cavity before a significant level decrease occurre Nuclear oversight and management personnel continued to spend substantial time in the plant. The plant monitoring program was further enhanced this period to provide the ability to track and trend observations. Some negative trends were identified, such as improper seismic restraint of equipment, although it appeared that corrosion of fasteners in systems such as salt water cooling went unnoticed until identified by NRC inspector Progress was observed in the performance of safety assessment This was demonstrated by the Onsite Review Committee, who appeared to be critical in their periodic reviews. However, weaknesses were at times noted. Immediately after the November 1990 inadvertent Unit 2 containment spray actuation, licensee management was slow to communicate to the NRC the actions being taken or considered to support continued plant operation. The licensee initially gave the appearance that this justification was based primarily on a previous containment spray experienc In-depth evaluation by the NRC subsequently determined that actions taken by the licensee were generally appropriat Additionally, when an erosion/corrosion problem was identified with non-safety related feedwater piping in Unit 2, the licensee restarted and operated for month prior to performing inspections on other Unit 2 piping susceptible to the same phenomeno The need for a more questioning attitude was at times demon strated. For example, Station Technical and Operations personnel excluded some steam trap positions from evaluation during technical assessment of Unit 2 AFW pump problems. In addition, a Unit 1 circuit breaker which was required by the TS to be locked open was found not properly locked after it had been checked at least three times by operator The licensee made upgrades to the corrective action program, including training for all personnel and lowering of the threshold for generation of nonconformance reports (NCRs). In general, NCRs were issued when appropriate; however, exceptions were noted, such as a weakness in the NCR procedure which did not require initiation of an NCR for failed surveillance test An NCR also was not initiated when a loose taper pin was found in a recirculation system check valve. Corrective actions were generally timely and effective in preventing recurrence of events, although there were several instances wherein similar failures occurred due to inadequate follow-through on identified problems. Examples included repeated ASCO solenoid valve failures in Unit 1 and a safety injection tank relief valve that failed open, placing Unit 3 in a Technical Specification action statemen Independent Safety Engineering Group (ISEG) reviews of industry experience were generally effective, with the exception of an improper review of actions associated with NRC Bulletin 89-02 that resulted in some check valves not being included in the in-service testing progra In general, improvement was noted in the quality of submittals to the NRC. Notable examples included the Units 2/3 shutdown cooling valve auto-closure interlock removal TS change, and submittals to support the Unit 1 full-term operating licens However, diversion of resources to Unit 1 affected the timeli ness of Units 2 and 3 licensing submittals (e.g., Unit 2 outage related TS changes).
Inspectors identified weaknesses in the licensee's assessment of potentially reportable 10 CFR Part 21
issues. In response to these findings, the licensee took action to strengthen this progra Most 10 CFR 50.59 evaluations were well documented and demon strated a good technical rationale, although one was not generated for the addition of the mixed waste handling facilit In addition, several instances were noted wherein the FSAR did not reflect existing plant configuration (e.g., minimum required SWC flow).
Three Severity Level IV violations and one Level V violation were identified during this assessment period, along with two non-cited violations. These were minor in nature and did not indicate a programmatic breakdow. Performance Rating Performance Assessment -- Category 2, Improvin. Board Recommendations The Board recommends that the licensee emphasize more thorough assessment of plant problems and continued implementation of an aggressive audit program. Efforts to ensure effective imple mentation of the corrective action program, update the FSAR, and improve the quality and timeliness of licensing submittals should continu IV. SUPPORTING DATA AND SUMMARIES A. Licensee Activities The three units operated routinely at nominal full power (for Unit 1, 91%) during the SALP period, except for the events or outages identified belo Unit 1 April 30, 1990 Automatic trip caused by indicated low flow in one reactor coolant loop. Flow transmitter was replaced; Unit operation resumed on May May 15, 1990 Manually tripped from full power following loss of feedwater flow to "C" steam generator (SG).
Short circuit during maintenance actuated the SG high level trip and closed "C" SG feedwater isolation valve. Unit restarted on May 2 June 30, 1990 Shut down for Cycle 11 refueling and maintenance outage, including replacement of thermal shield supports. Operation resumed in mid-March, 199 April 20, 1991 Shut down for SG tube leak repairs; restarted on May 2 May 28, 1991 Manually tripped because of two dropped control rod The Unit returned to power on May 3 June 24, 1991 Shut down to repair instrument air leaks inside containment. The Unit restarted on June 2 Unit 2 March 9, 1990 Shut down for pressurizer safety valve testing and adjustment; returned to power on March 1 July 2, 1990 Shut down to repair leakage in feedwater bypass piping (resulted from piping erosion/corrosion).
Operation resumed on July 5, 199 July 27, 1990 Shut down for inspection of SG feedwater sparger (after damage was discovered in Unit 3).
After similar repairs, operation resumed on August 2 October 21, 1990 With Unit 2 at full power, the steam-driven AFW pump was found to have been inoperable since August 24 due to an isolated steam tra November 20, 1990 While at full power, inadvertent actuation of the engineered safety features actuation system (during testing) resulted in a containment spray actuation. Followup testing identified degraded electrical connectors for control rod drive cable Unit 2 was shut down on November 23 to facilitate repair, restarting on November 2 December 6, 1990 Trip from full power on loss of power to non vital instrument bus. Operation resumed on December 1 March 10, 1991 Trip from 77% power on failure of control ele ment drive mechanism (CEDM) control system power supply. Operation resumed on March 1 April 10, 1991 Manual trip after controlled bleedoff (CBO) flow ceased from one reactor coolant pump seal assem bly. After seal replacement (involving mid-loop conditions) operation resumed on May 1 Unit 3 February 23, 1990 Reactor trip due to a main steam isolation sig nal during relay testin Resumed operation on March 4. Power reduced briefly on March 5 to evaluate pressurizer safety valve leakag April 14, 1990 Shut down for Cycle 5 refueling outag Damage to the SG feedwater spargers was discovered and repaired. Operation resumed on July 1 September 28, 1990 Containment emergency sump suction valve found to have been open for four days, rendering one train of ECCS/containment spray inoperable and potentially compromising containment integrit March 15, 1991 Trip caused by momentary loss of power from an uninterruptible power supply. After repairs, operation resumed on March 1 May 17, 1991 Shut down to repair main generator hydrogen leak. Operation resumed.on June 1 B. Inspection Activities Fifty-four routine and special inspections were conducted during this assessment period (February 1990 through July 1991) as listed belo Significant inspections are listed in paragraph IV.. Inspection Data Inspection Reports 90-04, 90-07, 90-08, 90-10 through 90-20, 90-22 through 90-28, 90-30 through 90-43, 91-01, 91-02, 91-03, 91-05, 91-07 through 91-19, 91-21, 91-22, and 91-24. Four of these reports summarized management meetings, and two reports documented enforcement conference. Special Inspection Summary Special inspections included the following:
90-14 April 2 -
20 and April 30 - May 11, 1990: Three 90-15 inspections to assess design, engineering, and 90-16 associated quality verification activitie September 13 - 28, 1990:
Emergency Operating Procedure October 9 - 12, 1990:
Allegations related to radiation protection practice October 1 through November 15, 1990: Review of two licensee-identified TS violations involving the misalignment of valves which resulted in inoperable safety equipmen January 14 - March 22, 1991: Setpoint methodology team inspectio March 11 - 15, 1991:
Implementation of Regulatory Guide 1.9 March 4 - April 15, 1991: Unit 1 operations and maintenance activities associated with misalignment of a containment spray valve (CV-514).
p
C. Enforcement Activity Inspections during this period identified 23 cited violations. Two of these (licensee-identified TS violations involving misalignment of valves in Units 2 and 3 which caused inoperability of important safety equipment) were categorized Severity Level III and resulted in the issuance of a civil penalty (Inspection Report No. 90-37).
D. Confirmatory Action Letters Non E. Licensee Event Reports LERs were issued for the three units during this assessment period as shown below. One security LER (reported under Unit 1) was also issued. One Unit 2 LER (90-11) was a voluntary repor Unit No. of LERs LER Numbers
26 90-04 thru 90-20; 91-01 thru 91-09
23 90-01 thru 90-16; 91-01 thru 91-07
16 90-01 thru 90-13; 91-01 thru 91-03