IR 05000213/1987010

Insp Rept 50-213/87-10 on 870413-17.Deviation Noted: Failure to Follow Procedures Generation Package Guidelines

ML20234E742
Person / Time
Site:	Haddam Neck File:Connecticut Yankee Atomic Power Co icon.png
Issue date:	06/24/1987
From:	Blumberg N, Crescenzo F, Prell J, Denise Wallace NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20234E721	List: IR 05000213/1987010 ML20234E718 ML20234E731
References
50-213-87-10, GL-82-33, NUDOCS 8707070666
Download: ML20234E742 (13)

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U.S. NUCLEAR REGULATORY COMMISSION

REGION I

Report N /87-10 Docket N License N DPR-61 Licensee: Connecticut Yankee Atomic Power Company P. O. Box 270 i Hartford, Connecticut 06141 l Facility Name: Haddam Neck Inspection At: Haddam, Connecticut and Waterford, Connecticut Inspection Conducted: April 13-17, 1987 Inspectors: ) ;

A. Prdll, Reactor Engineer

[//d/[7 date / J,/ 6 /11 1 T. Wallace, Reac't r Engineer ddte'

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. Crescenzo, if censig Examiner 6/n (ate'

Other Part pants:

NRC Headquarters: J. Bongarra, Engineering Psychologist, NRR Consultants to the NRC: L. Defferding, Senior Research Engineer, Pacific Northwest Laboratories A. Sutthoff, Research Specialist, Battelle Laboratories Approved by:

Norman J. Blumferg, Chief M $ fl f7 dats *

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Operational Pfograms Section,A B, DRS Inspection Summary: Routine Announced Inspection On April 13-17, 1987, Report No. 50-213/87-10 8707070666 870629 PDR ADOCK G5000213 G PDR

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Areas Inspected: Licensee conformance to the NRC approved Procedure Generation Package (PGP) regarding the development and implementation of their Emergency Operating Procedures (EOPs). Areas examined were the Administrative Program; Technical Adequacy; Writers Guide conformance; Validation / Verification Program; Training Program; Simulator exercise; and independent verification of valve lineup Results: One deviation was identified - Failure to follow procedures genera-tion package guideline l

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DETAILS 1.0 PERSONS CONTACTED 1.1 NORTHEAST UTILITIES

• Bray, Assistant Supervisor, Simulator Training

• R. Brown, Operations Supervisor

• Bouchard, Unit Superintendent C. Libby, Supervisor, Operations Quality Assurance

• Miller, Jr. , Station Superintendent 1.2 US NUCLEAR REGULATORY COMMISSION A. Asars, Resident Inspector .

• P. Swetland, Senior Resident Inspector The inspectors also interviewed other personnel during this inspection perio * Denotes those present at the exit meeting conducted on April 17, 198 .0 EMERGENCY OPERATING PROCEDURES The purpose of this inspection was to verify that Haddam Neck's Emergency Operating Procedures (EOPs) were written, verified and validated' in accordance with the licensee's NRC approved Procedures Generation Package (PGP) and training was conducted on the use of the procedure .1 REGULATORY REQUIREMENTS / REFERENCES i

Regulatory Guide 1.33, Rev. 2 - February 1978, Quality Assurance Program Requirements (Operations).

ANSI N18.7-1976, Administrative Controls and Quality Assurance for the Operational Phase of Nuclear Power Plant *

Westinghouse Owners Group (WOG) - Emergency Response Guidelines i (ERG) - High Pressure Version, Rev. 1, September 198 l t

Generic Letter 82-33, Supplement 1 to NUREG-0737 - Requirements for Emergency Response Capabilit * NUREG-0899, Guidelines for the Preparation of Emergency Operating Procedure l

Technical Specifications, Connecticut Yankee Atomic Power Co.,

Haddam Neck Plant, December 27, 198 *

Emergency Operating Procedures Generation Package, Revision 1, July 198 i l

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i 2.2 PROGRAM REVIEW f

The licensee's program for preparation of E0Ps was reviewed to verify that .

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The licensee has developed a Procedure Generation Package (PGP)

which includes Plant Specific Technical Guidelines, a Plant Specific Writers Guide, a description of the program used for verifying and validating the licensee's E0Ps, and a description of the program for training operators on E0P *

The licensee has developed emergency operating procedures (EOPs)

consistent with the guidance of Haddam Neck's PGP Writers Guide and NUREG-089 *

The E0Ps use a consistent format, which was easy to follow and i was as defined in their proposed PG *

The operators have been trained to use the E0Ps and the E0Ps ;

were useabl '

Differences between Westinghouse's Generic Guidelines and the licensee's specific E0Ps were identified and justifie !

The licensee had an administrative program for developing the {

E0Ps and controlling changes to the !

The E0Ps were technically adequate and capable of placing the plant in a safe condition following a reactor trip or actuation of the safety injection syste .3 PROGRAM IMPLEMENTATION Procedures listed in Attachment A were reviewed by the inspectors against the requirements and commitments of paragraph . ADMINISTRATIVE PROGRAM The inspector reviewed the program for controlling Temporary Procedure Changes (TPCs) to the E0Ps to ascertain whether proper controls were being exercised over their us Four TPCs were reviewed and the following items were verified for each TPC reviewed:

Each TPC was properly classified as either an " Intent" or "Non-Intent" chang *

An adequate description was given of the procedure l chang I l

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Suitable reasons for the changes were described on the {

TPC form, i a

Authorizations were documented as require *

PORC review of each TPC was documente *

PORC review occurred within 14 days of the shift supervisor's approval, as administratively require In addition, the inspector reviewed the E0Ps affected by TPCs to determine if the changes were entered into the procedures and whether the E0Ps had been revised within 120 3 days of TPC approva !

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2.3.2 TECHNICAL ADEQUACY l

l The inspectors compared seven E0Ps against the WOG-ERGS and also performed concurrent evaluation of the technical adequacy of the E0Ps. During this review, the E0Ps were ;

reviewed for consistency with the WOG-ERGS, against the step-by-step verification documentation and against the l l

documentation which justified those steps which deviated from the WOG-ER ] 1

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2.3.3 HUMAN FACTORS

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.l Five pages from each of five E0PS were reviewed to deter- 1 mine the extent to which they followed the format and -

content instructions committed to in the Haddam Neck PGP Writers Guide and whether they met the objectives found in NUREG-089 I 2.3.4 VALIDATION / VERIFICATION PROGRAM  !

The Connecticut Yankee Atomic Power Company E0P validation program is an ongoing program that utilizes throe l

validation methods to determine the E0Ps accuracy and <

applicabilit These methods are Table Top, Walkthrough in the Control Room, and Plant Specific Simulated Accident Scenario Although not all of the above methods are required to validate each E0P, the simulator walkthrough method is the most complete since the E0Ps are evaluated under more l realistic conditions. During the validatinn process, error summary forms are used to document acceptance of procedural steps and make recommendations for corrections. Cognizant operations personnel then evaluate the error summary form

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and revise the E0Ps accordingly. All E0P revisions are verified and validated in accordance with the validation progra i An inspector reviewed the test scenarios that have been run on the plant specific simulato These scenarios were found to have tested 25 of 42 E0Ps. The inspector veri-fied, on a sampling basis, that the discrepancies listed on the error summary form had been corrected in the procedures !

and that the scenarios reflected the guidance in the PG The inspectors verified, on a sampling basis, that the error summary forms were complete and that adequate administrative oversight was being exercised in their us Inspectors compared valve lineups used in Procedure ES-1.4, " Transfer To Two Path Recirculation" against P&ID drawing number 16103-26010, " Safety Injection System".

Comparisons were also made between two E0Ps and the control room main panel to determine whether:

The controls / displays identified in the E0Ps as being in the Control Room were there;

The control / display nomenclature used in the E0Ps was comparable to that found in the control room; and,

The displays could be read to the accuracy require"d by the E0P .3.5 TRAINING A review of the training program was made by reviewing )

training, records and course outlines, and by interviewing i training personne A tour of the training center _ was conducted and comparisons raade between the simulator's control panels and the plant's control pane .3.6 SIMULATOR An exercise of the E0Ps was conducted on the Haddam Meck i simulator. The exercise had two objectives: I

To determine whether the E0Ps were usable for the level of qualifications, training and experience of the operating staff, and

To determine whether the E0Ps are compatible with the minimum number, qualifications, training and exper-ience of the operating staf !

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l Five simulator exercises were developed to cover the subset of the E0Ps that had been reviewed for the audit: I

Reactor Trip with Steam Injection; j

Small Break LOCA in Containment; i

- Steam Generator Tube Rupture; )

Loss of Heat Sink with ATWS; and, I

Steam Line Break and.LOCA in Containmen These scenarios were chosen because they exercised a large portion of the E0Ps under review, and they covered a variety of emergency situation .4 QA/QC INVOLVEMENT IN E0Ps An inspector contacted Quality Assurance in order to determine what role QA had in the development and validation of the E0P QA management stated that E0Ps are considered to be auditable items under the QA program. At the time of this inspection, no audits of I the E0P program had been don '

2.5 FINDINGS 2. ADMINISTRATIVE PROGRAM During the review of TPC forms, the inspector verified that all necessary information was available on the TPC and that ';

technical information was adequate. TPCs were verified to have been reviewed by PORC within 14 days of shift supervisor approva The inspector reviewed administratively controlled copies '

of E0Ps in the control room and the station's document room and verified that the station superintendent's approval had been given to exceed the 120 day E0P revision requiremen Six months old TPCs were found which had not been incorp- j orated into the bodies of the procedures kept in the i station's document room. The TPC form itself had been '

inserted into the procedure, but the body of the procedure did not reference the changes. The inspector determined that this practice did not deviate from station adminis-trative procedures, but expressed his concern that these changes were still not incorporated into the E0Ps. The licensee stated that because major revisions to the applicable E0Ps were underway, the revision for the TPCs, which constituted a small part of the major revision, had been slowed down considerably. The licensee attributed-this slowness to lengthy turn-around times for the applicable safety evaluations being-performe .

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Control room copies of E0Ps were found to have TPC forms inserted in the procedures and hand written incorporations of these TPCs in the procedure bodies. These handwritten changes were performed in various ways, including:

• Handwritten in pencil or pe *

A handwritten reference to the following page written under the applicable ste *

Typed changes with additional handwriting posted into the procedure bod The inspector expressed his concern over the perceived lack of an established method for TPC incorporation and questioned the licensee whether a formal method existed to incorporate TPCs into procedures. The licensee stated that no such directions existed. After further discussions, the licensee committed to developing a formal method for timely incorporation of TPCs into procedures. The licensee also expressed a commitment to decrease the turn-around time for safety evaluations in order to speed up the procedure revision proces The inspector had no further concern .5.2 TECHNICAL ADEQUACY The E0Ps compared well with the WOG-ERG Minor discre-pancies were found that were needed to compensate for the specific plant design and/or the technical specification .

Several improvements were noted in the E0Ps, such as adding '

a step to periodically check what plant equipment should be running and rewording some of the poorly written ERG step .5.3 HUMAN FACTORS The human f actors review involved a comparison of the E0P with the Writers Guide and with NUREG-0899, Discrepancies were grouped into five main areas. A summary of the major ,

issues for each of the headings is provided below, listed I in descending order of safety significanc Specific comments and examples of the major issues are provided in Attachment Logic Terms The Writers Guide presents definitions and format instructions regarding the writing of conditional statements using logic term While the instructions provided were incomplete, those which were provided were l not applied correctly within the E0P. Three major areas of '

concern were identified:

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The use of AND and OR (together and separately) within action statement *

The inappropriate structuring of ,IF, THEN statement *

The use of the implicit IF NOT in the Response Not Obtained (RNO) colum Referencing and Branching Improper referencing and branching to other procedures and sections of procedures can be disruptive and cause unnecessary delays. Therefore, it is important that format and structure be consistently applied. The E0Ps contained the use of a number of trans-ition terms which were undefined in the Writer. Guide and inconsistent with the guidance provide Notes and Cautions The human f actors review revealed that Cautions and Notes in the Haddam Neck E0Ps were often misused by their structure as directives or inclusion of inappropriate information (i.e., non critical information in Cautions). It was noted that both Notes and Cautions lacked sufficient emphasis to attract the operators'

attentio Sentence Structure It was found that the E0Ps utilized inconsistent structural methods for similar types of statements, conflicting not only with the guidance provided in the Writers Guide, but utilizing a number of different structures for one type of statement within a single E0P, e.g., three different methods of listing expected plant response were found within procedure E-0. In addition, action statements were found which lacked verbs and which included two to three directives within one ste M_ miscellaneous A number of other problems were found in the E0Ps including lack of an adequate peacekeeping method at the step level, use of vague terminology, inconsistent use of abbreviations and acronyms, a temporary change method with potential for confusion, and a lack of an adequate method for dealing with continuously monitored situations within the procedure The licensee's failure to follow the Writers Guide is detailed in a deviation identified in paragraph 2. .

, 10 2.5.4 VALIDATION / VERIFICATION Verification Haddam Neck's PGP, as submitted for review, described the verification of the E0Ps for correctness, using the Haddam Neck Writers Guide as a basi s for evaluation. The program is described as being carried out by a team of personnel from the Operations, Training, and Reactor Engineering groups. A checklist is used as a guide i to the process and discrepancies are forwarded to the E0P writer' for correction, with corrected procedures then submitted for validatio Actual verification activities at Haddam Neck were carried out by the E0P writer and control- room personnel on a desk top basis, with subsequent verification (following plant validation) provided through a safety evaluatloa review performed by the NUSCO Reactor Engineering Branc No human factors personnel were involved in verification, and no control room walkthrough was performed to check correspondence of control panel nomenclature with that shown in the procedures. During interviews regarding the verification process, the E0P writer for Haddam Neck stated that the Writers Guide was not used in the development of the procedures, and indicated that the focus during veri-fication was on the technical accuracy of the procedure A control room walkthrough by the inspectors revealed that a number of the references to instrumentation in the E0Ps were inconsistent to the nomenclature found in the control room. Some examples where the nomenclature in the E0Ps was different than that found on the control panels were:

E0P ES-1.3 page 2/4 step 1 refers to "SIWL Switches". !

The control room panel for these switches is labeled

" Core Cooling Auto - Man, A, B."

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E0P ES-1.3 page 3/4 step 3b refers to " Containment Suction Valve RH-MOV-22". The control room panel for this valve is labeled " Containment Sump Suction",

a E0P ES-1.3 page 3/4 step 3K refers to MOV valves

"RH-MOV-33A and B". The control room panel is labeled

"RHR to Charging".

Subsequent tests of the E0Ps on the simulator indicated that the nomenclature disparity between the E0Ps and the control room panels presented no confusion to the operators. The operators were trained on and familiar with the nomenclature used in the E0Ps and had no problens identifying the proper switch or indicator. This disparity did, however, lead to questioning the adequacy of the

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verification program used by the license The licensee stated . that as part of the current control room design review program now in process, all E0Ps would be checked l against the control room panel :

On page 39 of the licensees approved PGP, section 2.2 "EOP Verification Objectives" states in part 'that "...EOP verification can be considered adequate when the following basic objectives are satisfied..." Technical accuracy -

Proper incorporation of ... plant-specific technical aspects from ... plant hardware have been incorporated correctly." Page 41 paragraph A.2.2 further states in part

".. CY Operations Department members will be responsible for written correctness and technical accuracy. . .". Failure to correctly translate control room switch and indicator nomenclature into in E0Ps is a part of the deviation j

identified in paragraph 2.5.7 belo Validation The validation process is described in the Haddam Neck PGP as a determination that an operator using the E0PS can recognize the malfunction, select the right procedure or procedures, mitigate the accident in a ' timely manner and return the plant to a safe and stable conditio The PGP indicates that table top review, control room walkthrough, and simulator exercises will be used as available to validate the E0Ps. The validation program is described as ongoing, paralleling the- operator . training program, with a system for feedback from the operator Initial simulator validation was performed in conjunction with pre-implementation training. Scenarios utilized were chosen to exercise a wide variety of E0Ps and . included multiple sequential and simultaneous failures. Discre-pancies and problems identified during the validation were corrected during the initial proces The validation, like the verification process, utilized by Haddam Neck was adequate with regard to the technical aspects of those procedures validated on the simulato However, only two of the FRPs were exercised on the {

simulator, and n control room walkthrough was performed on j those which ha ,'not been validated in the simulator. The l

result is that the useability of a number of E0Ps' has not l been validated, particularly with regard to their use by I minimum control room staf I l

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l 2.5.5 Training The Haddam Neck E0P training program consisted of classroom

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lectures and simulator exercises. Training addressed the {

' l philosophy and purpose of the E0Ps, their technical bases i and content, and the guidelines for their use. Operators l were evaluated through written exams and instructor !

critiqu Simulator training involved the exercise of a I wide variety of E0Ps by all operators on a variety of scenarios including multiple sequential and simultaneous failure Continuing training entails additional simulator experience

j and classroom lectures. Thorough documentation of lesson i plans and participation has been maintaine Revisions or j changes to the E0Ps are communicated to operators at the l time of the change, and are also incorporated into the next i scheduled operator training sessio l The Haddam Neck E0P training program was well-designed and well-documented and should provide the operators with appropriate training but contains one major deficit: the I same FRPs which were not validated on the simulator were i not exercised by operators during simulator trainin These procedures were covered in the classroom portion of the training program; however, operators were not given the opportunity to use these procedures and, therefore, were not evaluated on their us .5.6 Simulator l

No major procedural deficiencies were observed during the simulator portion of the audi The most significant problem identified had already been identified by Haddam Neck and was awaiting approval for chang A number of implementation problems were noted during the exercises. They are as follows:

While the Writers Guide indicates that bullets (*)

will be used to indicate actions which can be performed in any sequence, the E0Ps use of bullets appeared to signify actions which are optiona *

Cautions and notes appeared to be skipped over by procedure reader In one situation, a later error was attributable to not reading the caution statemen *

Temporary Procedure Change forms (TPCs) appeared to be skipped over by reader .

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2. Summary The technical content of the Haddam Neck E0Ps was reviewed in detail and determined to be consistent with the WOG ERGS and their PGP. A human factors review of their Writers Guide, however, revealed numerous deficiencies that require attentio These deficiencies included, but were not limited to, the incorrect and inconsistent use of logic statements in the E0P, and a lack of correlation between instrumentation nomenclature in the procedures and that in the control room. The validation and training programs were found to be deficient for all but two of the FRP There was also some concern about the amount of time necessary to obtain utility approval for changes to the E0Ps and how the E0Ps, were being implemente In . summary, no human factors experts were involved in the initial E0P validation and no accommodation has been made for human factors input in the -future. The magnitude of this omission is reflected in the number of human factors issues, related to the Writers Guide, identified in the E0Ps and by the disparity between E0P and Control Room nomenclature. Based upon the above and as detailed in paragraphs 2.5.3, 2.5.4, 2.5.5, 2.5.6, and Attachment B this is a deviation of the licensee's commitment to follow its NRC approved Procedure Generation Package (50-213/87-10-01).

3. I_ndependent Verification The inspector independently verified that the various levels and values given in the E0Ps (ESI.3 and FR-S.1) were consistent with the indicators found in the control room and that the operators were knowledgeable of {

where various switches were located. The inspector also verified by review of the P&lDs that the correct valves used for lining up for two i

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path circulation were properly identified in the E0P '

4. Exit Interview An exit meeting was held on April 16, 1987, to discuss the inspection scope and findings, as detailed in this report (see ,.aragraph 1.0 for attendees).

i At no time was written material given to _the licensee. The inspector '

determined that no proprietary information was utilized during this inspectio l (

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ATTACHMENT A

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CONNECTICUT YANKEE ATOMIC POWER COMPANY PROCEDURES REVIEWED )

l ACP 1.2-6.5, Rev. 19, Station Procedures q

ACP 1.2-6.4, Rev. 19, Temporary Procedure Change ES-1.3, Rev.1, Transfer to RHR Recirculation 4 l

ES-1.4, Rev.1, Transfer to Two Path Recirculation i E-0, Rev. O, Reactor Trip or Safety Injection E-I, Rev. O, Loss of Reactor Or Secondary Coolant ES-3.3, Rev. O, Post-SGTR Cooldown Using Steam Dump ECA-3.3, Rev. O, SGTR Without Pressurizer Pressure Control FR-H.1, Rev. O, Response To Loss of Secondary Heat Sink FR-I.1, Rev. O, Response to High Pressurizer Level FR-S.1, Rev. O, Response to Nuclear Power Generation /ATWS

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ATTACHMENT B REVIEW OF WRITERS GUIDE 1. The Writer's Guide, Section 4.2.3, pages 19-20, presents definitions ' and format instructions regarding the writing of conditional statements using logic terms. -The instructions provided are incompl ete , and those that the provided are not applied correctly within the E0 The following problem areas were identified: The Writer's Guide, Section 4.2.3, page 20, indicates that AND and OR are not to be used within the same logic statement. However, there are occasions when it is necessary to use both in the same sentenc In those cases, it is critical that the logic statement -(

be structured in such a way that only one meaning is possible. The E0Ps contained several examples of the incorrect use of AND and OR in a sentence. The Writer's Guide should be expanded to provide guidance on the correct way to use these terms togethe For additional guidance on possible methods for presenting this type of statement, see NUREG-0899, Appendix The following occurrences of this type 'of problem were identified:

E0P E-1, Step 2 RN0:

(a) T any SG pressure is decreasing in uncontrolled manner (b) or completedly depressurized (c) and SG has not been isolated (d) then go to E-2 FAULTED SG ISOLATION, Sten 1."

This conditional statement has two possible meanings: If (a) or both (b) and (c) If both (a) and (c), or both (b) and (c) {

E0P E-1, Step 8-Containment pressure - (a) LESS THAN 35 PSIG and (b) stable or (c) I decreasin This statement has two possible meanings: both (a) and (b) or only (c)  ! both (a) and (b) or both (a) and (c)

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2 Attachment B b. When used as conjunctions, "and" and "or" join lists, multiple actions or alternative When used as logic terms, they indicate decision points. It is important that appropriate emphasis be used when these words are being used in a conditional statement, to signal to the operator that a decision point has been reached. When used to indicate multiple actions, alternatives or a list, "and" and '

"or" should not be emphasized as logic terms. The Writer's Guide should be expanded to provide explicit direction on the different use and formatting of "and" and "or". The E0Ps contain a number of'

different types of formatting for these words and should be revised to be consistent with the expanded Writer's Guide: 1 E0P ES-3.3, Step 5.b:

l Manually or locally dump steam from intact SG(s):

Use atmospheric vent valv E no intact SG available, THEN perform the following:

Use faulted SG i-OR-Go to ECA-3.1. SGTR WITH LOSS OF REACTOR COOLANT-SUBCOOLED REC 0VERY DESIRED, Step l This step uses the conjunction "or" in two different format Because "or" is functioning as a conjunction in both uses, it should be formatted consistentl While the Writer's Guide lacks format information for the use of "or" as a conjunction, it should also be noted that neither use of "or" within the above step is consistent with the guidance provided in Section 4.2.3 of the Writer's Guide for the emphasis of the log term O Other examples of this type of problem found in the E0Ps sampled:

E0P STEP PROBLEMS E-0 1 OR

" or

" and

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4 and

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7 -OR-E-1 6 -OR-ECA- or

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hb OR FR- l' -0R-t c. The Writer's Gefde provides direction on the use of the logic sequence li %; 4 in Section 4.2.3, page 1 There are a number of

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3 Attachment B statements within the E0Ps which should be structured as IF, THEN ,

statements but which are no For example: '

E0P E-0, Step 4:

CHECK IF SI IS ACTUATE 0: '

SI WL switches trippe )

SI pumps START and valves actuate I Refer to EPIP 1.5-1 (Emergency Assessment)

In addition, there are a number of IF NOT, THEN statements which are i not formatted consistently with the guidance provided in the Writer's Guide, Section 4.2.3, page 19. For example:

E0P E-0, Step 4 RNO:

Check if SI is require IF SI is required, THEN manually I_F SI i s NOT required, THEN go to ES-0.1, REACTOR

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actuat f TRIP RESPONSE, Step This step conflicts with the format directions in the Writer's Guide, which indicates that the term IF NOT will not be spli The step could be rewritten correctly as:

I_F SI is required, THEN manually actuat I_F NOT, THEN GO TO ES-0.1, REACTOR TRIP RESPONSE, Step 1 It should be noted that the first sentence, " Check if SI is required." is not necessary in this ste Other examples of these types of problems foui J in the E0Ps sampled:

E0P Step i'

E-0 5

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12 RNO

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13 ,

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14.1 RNO l

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E-1 1

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ECA- .

FR- "

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4 -Attachment B- The two column format used in the Haddam Neck E0Ps is structured so that the right hand column includes an implicit "if not" relation-ship to the left hand column (se'e Writer's Guide, Section 4.2.2, page 18). In a number of statements in the ECPs, the "if not" has been repeated in the right hand column, unnecessarily cluttering and complicating the procedure, and not taking . advantage of the RNO i structur E0P E-1, Step 6.b RN0:

IF neither condition satisfied, THEN DO NOT STOP SI PUMPS. Go to Step This step could be rewritten correctly as:

DO NOT STOP SI PUMPS. GO TO Step E0P ECA-3.3, Step 7.b RNO:

IF .neither condition satisfied, THEN 00 NOT STOP S1 PUMPS. Go E ECA-3.1, SGTR WITH LOSS OF~ REACTOR COOLANT-SUBCOOLED RECOVERY DESIRED, Step This step could be rewritten correctly as:

DO NOT STOP SI PUMPS. GO TO ECA-3.1, SGTR WITH LOSS OF REACTOR COOLANT-SUBCOOLED RECOVERY DESIRED, Step Other examples of this type of problem found in the E0Ps sampled:

E0P STEP R 1 E-1 ECA- .a

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FR- " .b The following logic statements are formatted in a manner inconsis-tent with the guidance provided in the Writer's Guide, Section 4.2.3, pages 19-20, and should be corrected:

E0P STEP PROBLEM:

E-0 1 Needs comma before THEN

" "

1 " " ' - ~

E-1 2 Needs capitalization 2. Referencing and branching to other procedures and sections of procedures can be disruptive and cause unnecessary delay Therefore, it is important that format and structure be consistently applie ,

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a. The Haddam Neck Writer's Guide, Section 4.2.5, page 21, defines "go l to" as the transition term to be used within the E0Ps and prov_ ides '

format instructions. The E0Ps, however, use a number of- different terms to indicate movement within and between' E0Ps. The Writer's Guide should be revised to define the minimum number of terms necessary for clear instruction to operators on transitions and the E0Ps should be revised accordingl j

E0P E-0, Step 4: I l

. . . . . . Refer to EPIP 1.5-1 (Emergency Assessment) i E0P E-1, Step 8.b:

WHEN containment pressure less than 35 psi )

THEN do Step 8 Other examples of this type of problem found in the E0Ps sampled: I J

E0P STEP TERM USED E-0 Symptoms "see"

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4 " refer to" 6 "PER" E-1 "do"  ;

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10 " return to" -

ES- "in accordance with" -

" "per" FR- " return to"

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b. The Writer's Guide, Section 4.2.5, page 21, indicates that the i

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procedure number, title (in caps) and step number should be included in every reference statement. The following ' steps are inconsistent with the Writer's Guide:

E0P-EO, Step 3.a:

.....THEN go to ECA-0.0, Station Blackout, Step Per the Writer's Guide, Section 4.2.5, page 21, this step should be rewritten as follows:

.. ..THEN go to ECA-0.0, STATION BLACK 0UT, Step E0P E-0, Step 3.c:

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Go to E0P-3.1-49, PARTIAL LOSS OF D j

Per the Writer's Guide, this step should be rewritten.as follows: {

Go to E0P-3.1-49, PARTIAL LOSS OF DC, Step i l

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6 Attachment B It should also be noted that the procedure designator E0P-3.1-49 is inconsistent.with the system described in Section 2, pages 6-9, of the Writer's Guid Other examples of this type of problem found in the E0Ps sampled:

E0P STEP PROBLEM ES- Needs step number FR-H-1 1 Needs procedure number, title, step The Writer's Guide, Section 4.2.5, page 21, indicates that the transition term "go to" be shown in lower case letters. In order to signal to the operator that movement out of the step currently in use is required, all transition terms should be shown in caps and underline When moving within and between procedures is required, the potential for losing one's place in the procedure is increased. The Writer's Guide, Section 4.4, page 23, indicates that peacekeeping at the step level will be accomplished through the use of checkoff The E0Ps, however, do not provide any structured format for these checkoff The Haddam Neck Writer's Guide, Section 3.2, page 10, indicates that steps for performing operations or lists of valves will be placed on the backpage facing the step for which it is required. However, no formatting directions are provided in the Writer's Guide, with the ,

result that these "attehments" vary dramatically in structure. The Writer's Guide should be expanded to address the specific formatting directions for backpage information, as well as that for tables and figures to be included in the procedure bod . Cautions are used to describe a hazardous condition which can cause injury or equipment damage, and should describe the consequences of the hazar Notes are intended to provide supplemental information to 'the operato Neither Cautions nor Notes are to include action statement The human factors review revealed several problem areas related to Cautions and Notes: Cautions and Notes in the Haddam Neck E0Ps samples were found to contain directives and references which should be rewritten as action step Some Cautions lack a statement of the hazard at hand and possible consequences, and some Notes appear to include critical information more appropriately presented in a Caution statemen Following are instances of improper use and structure of Cautions and Notes:

E0P ES-3.3, page 2:

CAUTION: STEAM SHOULD NOT BE RELEASED FROM ANY RUPTURED SG IF WATER MAY EXIST IN ITS STEAMLIN ,

,

t

.

7 Attachment B l

This Caution lacks identification of the hazard and consequenc !

related to the existance of water in an SG steamline, i E0P E-1, Page 2: g l

NOTE: IF LOCAL HAS OCCURRED, SOUND PLANT EVACUATION j ALARM AND INITIATE CONNECTICUT YANKEE EMERGENCY 1 P LAN . I

\

This note has two problems. Fi rst, it contains a directive which '

more appropriately should be presented as an action step. Second, it refers to an emergency situation which would more appropriately be addressed in a Caution preceding the related action ste Other examples of these types of problems found the the E0Ps sampled:

E0P PAGE PROBLEM E-1

"

3 Caution contains action step 5 Both Cautions are action steps i ES- Both Cautions lack identification of i

"

hazard and consequence '

"

3 Caution Contains action step

"

4 Note should be Caution 5 Caution lacks identification of hazard l and consequence ECA- Caution contains action step FR- st & 4th Cautions: lack identification

"

of hazard and consequence 2 2nd & 3rd Cautions: are a logic sequence

"

"

3 Note contains an action step 4 Caution lacks identification of hazard

"

and consequence 5 Caution lacks identification of hazard and consequence )

Because of the nature of the information contained in Caution statements, it is important that they be distinguished from less critical information. The Writer's Guide should .be revised to i designate some form of highlighting for Caution statements, e.g., j circling the Caution with asterisk Also a unique method of calling attention to NOTES is neede !

i 4. Sentence structure is an important f actor in the presentation of clear and understandable instructions. The desk-top review identified several problem areas related to sentence structure in the Haddam Neck E0P The Writer's Guide, Section 6.3, page 33, and Figure 5, page 17, provides directions on the format for presentation of expected plant responses. Within the E0Ps, however, a number of different methods

.

<

t

.

'

(

, 8 Attachment B are utilized for formatting this -informatio The E0Ps should be revised to be consistent with the Writer's Guide and to be consistent within all E0P E0P E-0, Step 10: i VERIFY AUTO START OF DIESEL GENERATORS This step could be rewritten correctly as:

VERIFY DIESEL GENERATORS - STARTED i

E0P E-0, Step 15.c:

High pressure SI pump CHECK FOR FLOW-AMP METERS GREATER THAN 115 AMP This step could be rewritten correctly as:

i CHECK high ' pressure SI pump and meter - GREATER THAN 115 AMPS Other examples of this type of problem found in the E0Ps sampled:

E0P STEP PROBLEMS E-0 1 Lower case letters

"

"

2 Lower case letters 3 Should be " energized"; qualifiers belong

"

in first part, not in exp. res "

4 Lacks hyphen; lower case letters

"

5 Partial lower case

"

7 Lacks hyphen; lower case letters 8 Embedded expected response; two hyphens

"

"

11 Embedded expected response J i

12 Embedded expected response l

"

13 Embedded expected response l

"

14 Expected response; includes verb

" l 15.a & e. Embedded expected response

"  !

16 Lacks hyphen j E-1

"

1 Lacks hyphen; lower case letters j 3 Embedded expected response

" .

"

5 Lacks hyphen; lower case letters I 8 Lacks hyphen; lower case letters j ES- Embedded expected response 1 ECA- Embedded expected response 1

- _ _ _ -

.

9 Attachment B b. A number of substeps throughout the E0Ps lack verbs. These substeps appear to be intended to use ' the verb of their high-level . step, however, the mix of actual directives with ' these substeps could be confusing to the operato The E0Ps should be written with clear,'

concise statements indicating what action the . operator is to tak The following steps lack verbs in all or some of their substeps:

E0P E-1, Step 1: RCS pressure LESS THAN 1150 psig (1380 FOR ADVERSE CONTAINMENT)

This step could be rewritten correctly as: CHECK RCS pressure - LESS THAN 1150 PSIG (1380 FOR ADVERSE CONTAINMENT)

E0P E-1, Step 2:

ALL SGs PRESSURES - GREATER THAN 100 PSI This step could be rewritten correctly as:

CHECK all SGs pressure - GREATER THAN 100 PSI Other examples of this type of problem found in the E0Ps sampled:

E0P STEP E-0 1

"

"

n

"

a

"

"

"

E-1 3

"

"

"

ES- "

ECA- "

"

u y FR- "

_ _ _ _ _ - _ _ _

,

.

,

10 Attachment B

,

c. The Writer's Guide, Section 4.2, pages 13-16, indicates that steps are to be written concisely, describing just the task to be performed, and that complex evolutions are to be broken dow The Writer's Guide should be revised to explicitly state that no more J than one action is to be included in any one step. The following steps include more than one action:

)

E0P E-1, Step 5:

CHECK FRZR PORVS AND BLOCK VALVES:

This could be rewritten correctly as two distinct steps:  ;

CHECK PRZR PORV CHECK BLOCK VALVE (Note that the operator should be told if valves are opened or )

closed.) '

i E0P ECA-3.3, Step 4:

1) Open CH-MOV-298 (Charging Hdr to Aux. Spray),

throttle CH-V-2928 and CH-MOV-292C

)

This could be rewritten correctly as two distinct steps:

Open CH-MOV-298 (Charging Hdr to Aux. Spray).

Throttle CH-V-292B and CH-MOV-292C I

Open examples of this type of problem found in the E0Ps sampled:

E0P STEP I E-0 1

"

"

E-1 4 ECA- FR- "

"

_

.

, 11 Attachment B 5. A system of step numbering and indentation can assist the operator in moving through procedures without confusio The review of Haddam Neck E0Ps revealed several problems related to numbering and listing within the E0P The Writer's Guide, Section 3.3, page 10, and Section 4.2, page 16, indicates that bullets will be used to indicate that a sequence of actions may be performed in any orde According to the operators at Haddam Neck, they are trained to consider the bullete an  !

indication that one or more of the actions may be performed, but not all are require The Writer's Guide, E0Ps, and training program content should be revised to be consistent with each other with regard to this issu The following steps include substeps listed with bullets:

E0P STEP E-0 1

"

"

"

"

"

E-1 2 ECA- "

"

FR- The Writer's Guide, Section 3.3, page 10, indicates that step numbers will be followed by a period. However, in almost all cases within the E0Ps reviewed, the high level step number did not include a perio The E0Ps should be revised to be consistent with Writer's Guide and consistent within the procedures themselve . A number of statements in the E0Ps are vague and do not describe specific operator behaviors, which can result in directions which are unclear to the operato For example, the operators are sometimes instructed to perform an action "as required" with no criteria provided as to what the requirements ar In some cases, the term " stable" is use This term is specifically cited in the Writer's Guide, Section 6.4, page 33, as one not to be use In order to ensure that procedures are understood, directions should be defined quantitatively. Following uses of vague '

terms noted in the E0Ps:

i

'1

.

.

, 12 Attachment B I TERM E0P STEP stable E-1 E l

H g

'

g

"

10 l adequate ES- I as necessary E-0 5

"

{

ES- '

"

as required ECA- backpage/ normal E-1 4 when proper conditions exist ECA- backpage/ . Other weaknesses identified during the audit are noted below; The Haddam Neck Writer's Guide includes Table 2, " Abbreviations used in Procedures," yet the E0Ps include a number of abbreviations and acronyms which are not included in Table 2 or are included in Table 2 in another form. In addition, the E0Ps include multiple forms of i a number of abbreviations. In order to minimize confusion and )'

ensure consistently prepared procedures, all acronyms and abbreviations to be used in the E0Ps should be listed in the PG NOT INCLUDED IN TABLE 2 l

AE RMS '

au AU Bd RMS CARFANS CIAS/HCP Ckts DVM Elec. Au FW GPM gpm Mcp HCP LPSI MCB NIS NRV psig PSIG RMS

e

, 13 Attachment B l

SI-WL T

'

tave tem TP0 WL l

INCONSISTENT WITH TABLE 2

PZR Vice PRZR AC Vice ac

)

b. The E0Ps use several different methods of indicating plurals for acronyms, e.g. , SGS, SGs, SG(s), SG(S), The use of showing plurals in the E0Ps should be consisten c. The Writer's Guide, Section 5.0, page 27, and Figures 6 and 7, pages 29-30, provide guidance for the preparation of Critical Safety .,

Function Status Trees (CSFSTs), including the use of color. However, the CSFSTs in use in the control roo:' at Haddam Neck are - not in color. The CSFSTs should be revised to be consistent with the PG )

l

_